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MonitoringThe process of observing physiologic responses to surgery and anesthesia
Governs monitoring standardsAANA 
Monitoring goalreduce anesthesia morbidity and mortality
AANA standard 5Documentation
AANA Standard 6Equiptment
<b>AANA Standard 9</b><b>Monitoring Alarms: oxygenation, ventilation, cardiovascular, thermoregulation, and neuromuscular</b>
AANA Standard 1Anesthesia provider always present
AANA Standard 2Oxygenation, ventilation, circulation, and temperature continually monitored
Oxygenation Physical signsColor of skin, mucous membranes&nbsp;
Oxygenation MonitorPulse Ox, inhaled oxygen concentration
Oxygenation alarms and monitoringLow limit alarms&nbsp;
Ventilation physical signsbreath sounds, chest excursion
Ventilation monitorventilator, end tidal CO2
Ventilation alarms and monitoringDIsconnect alarm, tidal volume measurement, ETCO2, alarms
Circulation Physical signsPulse palpation, auscultation of heart sounds
Circulation monitorECG, BP, Heart Rate
Circulation alarms and monitoringECG, BP cuff, arterial line, pulse ox
Temperature physical signsskin
Temp monitorTemp probe
Temp alarmslow temp alarm&nbsp;
Number 1 liabiltyFailure to monitor and recognize
Alarm standardUse of variable pitch alarms and threshold alarms should be activated
Ideal alarmEasy to locate and recognize, evident despite other noises, allows for effective communication, elicits reduced false alarms
Beer lambert lawShines a light through the part of the body being measured. Light is absorbed differently by blood components and hgb
Pulse oximetryEstimated percentage of arterial hemoglobin that has O2
<b>Near infra-red light</b>940 nm-- absorbs more oxygenated hemoglobin&nbsp;
<b>Red light</b>66o nm-- absorbed more deoxygenated hemoglobin&nbsp;
Modification of Beer-Lambert Law"<span style=""color: rgb(35, 35, 35);"">Measuring
absorbance at two different wavelengths, one to detect oxyhemoglobin and the
other to detect deoxyhemoglobin</span>"
Specifically Beer's LawIntensity of transmitted light decreases exponentially as the concentration of the substance increases
Lambert's LawIntensity of transmitted light decreases exponentially as the distance travelled through the substance increases&nbsp;
Oxygen-hemoglobin dissociation curveHow easily hemoglobin in RBC bind to and release oxygen&nbsp;
<b>Left Shift curve&nbsp;<br></b>Hemoglobin has a higher affinity for oxygen, holds onto O2 more tightly and is less likely to release into tissue&nbsp;
<b>Left shift cause</b>Alkalosis, low temps, low 2,3- BPG, fetal Hb, Methemoglobimia, high O2 affinity Hb variants&nbsp;
<b>Right shift&nbsp;</b>Hemoglobin has a lower affinity for oxygen, meaning it releases it more easily into tissues&nbsp;
<b>Right- Shift caused by</b>Acidosis, hypercapnia, high temperatures, High 2,3- BPG, Low O2 affinity Hb variants&nbsp;
<b>2,3 DPG&nbsp;</b>A molecule that helps hemoglobin release oxygen -- special intermediate of glycolysis in erythrocytes.&nbsp;<br>Hypoxia- increase in DPG o unload oxygen to tissues&nbsp;
Pulse Oximetry accuracyAccurate within 2% when O2 (80-100%), accurate within 5% when below 80%
When to document room air saturationBefore sedation and preoxygenation&nbsp;
Pulse Ox positioningLateral: on down arm to ensure a pulse and blood flow&nbsp;
<b>Transmissive pulse ox</b>Sensor on a thin part of the body (finger, earlobe), uses light as a detector&nbsp;
<b>Reflectance Pulse Ox</b>Not a thin part (chest, forehead, feet), monitor perfusion in flaps.&nbsp;
RPO LimitationsVasodilation, trendeleberg, PPV
Factors affect Pulse Oxlow perfusion states, anemia, movement, room lights, cautery, dark nail polish, IV dyes (false low), sickle cell anemia&nbsp;
MethemoglobinAffect Pulse Ox: absorbs WL equally at 660 and 940, leadign to false spO2 reading of 85%. Can be caused by topical benzocaine, treat with methylene blue&nbsp;
CsrboxyhemoglobinInfluences pulse OX: picks up same as oxyhemoglobin, falsely elevates SpO2
Rare Pulse ox complicationBurn&nbsp;
Pleth Variablity IndexMeasures the change in Perfusion Index during breathing cycles, indicates the strength of the pulse signal
PVI calculationRatio of pulsatile AC infrared signal to non-pulsatile DC infrared signal. Expressed as a percentage ranging 0.02%- 20%&nbsp;
Estimating PVIusing the standard pulse ox pleth in a high speed setting and visually looking at the height and baseline&nbsp;
Preventing 93% of adverse effectsMonitor Capno and Oxi&nbsp;
Normal End-tidal capno waveform&nbsp;"<img src=""paste-ffcca6cc0db6aec693bca1796916f213e28ab530.jpg""><br>Phase 1: Baseline, inhalation<br>Phase 2: Exhalation Rise<br>Phase 3: Exhalation plateau"
End tidal CO2 reading&nbsp;End of exhalation (35-45)
ETCO2 vs PaCO2ETCO2 is 5 mmHG less than PaCO2 due to dead space&nbsp;
"<img src=""paste-59b337ab98d1f7733790e46093d57bf7e5df6afa.jpg"">"Decreasing End tidal: Hyperventilation&nbsp;
"<img src=""paste-6374cb60ad77dc49b1aa6de506789c3ccbbb8011.jpg"">"Apnea
"<img src=""paste-d273832a40a5f18ee1dd59f91b7dcc4f3ed9a345.jpg"">"Elevated baseline: CO2 rebreathing, air trapping, equiptment failure&nbsp;
"<img src=""paste-380fbbbb6049d37bf67681731e9445a9756cf0d3.jpg"">""<span style=""background-color: rgb(255, 255, 255);"">Shark fin: Incomplete or obstructed exhalation&nbsp;</span>"
"<img src=""paste-ad92e00badde1f9cf33c90f6fc9c2a33272a8ed2.jpg"">"Increased end tidal: hypoventilation&nbsp;
"<img src=""paste-1d63601f6fab62e7919e5818966a22467e6fb8ca.jpg"">"Cardiac Oscillations&nbsp;
"<img src=""paste-dfd01dbde420b329a76c34e5ea30ef9c747d311d.jpg"">""<span style=""background-color: rgb(255, 255, 255);"">Curare cleft: trying to take inspiratory breath inbetween cycle-- need more paralytic&nbsp;</span>"
Causes of increased CO2Hypoventilation, MH, sepsis, seizures, pain, tourniquet removal, rebreathing, bicarb admin, CO2 insufflation during laparoscopy
Decreases in CO2Hyperventilation, hypothermia, low CO, pulmonary embolism, Leak in airway system, accidental disconnect, cardiac arrest
Colorimetric DevicesQualitative, ph-sensitive color indicator&nbsp;
3 color rangesPurple - under 0.5<br>Tan- 0.5-2<br>Yellow- greater than 2&nbsp;<br>Normal= &gt;4
Colormetric issuesInaccurate during CPR <br>Gastric contents, mucus, and epi- false positive&nbsp;<br>Avoid- observe color change in the device with each breath&nbsp;
Fraction Inspired of CO2Amount of CO2 patient is inhaling, should be 0 (rebreathing co2)
Causes FiCO2 not at 0Exhausted sodalyme &amp; Faulty valve
End Tidal CO2Concentration of CO2 exhaled at the end of exhalation&nbsp;
FI of OxygenConcentration of oxygen you are delivering through the anesthesia circuit or auxillary port&nbsp;
ET of OxygenAmount exhaled&nbsp;
Oxygen extraction fractionFiO2 - ETO2
<b>Fi of gas</b>Should be what is dialed on vaporizer- detects the gas is turned on&nbsp;
<b>ET of gas</b>Amount of gas exhaled: mirrors brain concentration, used to calculate MAC&nbsp;
MAC of gasesIsoflurane: 1.15<br>Sevoflurane: 2<br>Desflurane: 6
Wash-In PhaseInitial phase when gas first administered. FI&gt; FA
Steady StatePhase where the gas has stabilized, Fi&nbsp;≈ ET (not exactly the same)
Wash-out PhasePhase during the emergence when anesthesia is being eliminated from body. ET&gt; Fi
<b>Calculating MAC&nbsp;</b>Et agent / MAC of drug = MAC&nbsp;<br>Ex: Iso ET- 0.95, Fi-1.2<br>0.95/ 1.15= 0.83
Computing ration of NO2 to O2&nbsp;Add L N2O to L O2<br>L N2O divided by total L&nbsp;<br>Subtract the percent N2O (above answer) from 100 to find ratio&nbsp;<br>EX: 2L N2O and 6L O2<br>6+2=8<br>2/8= 0.25 (25%)<br>100-25= 75% O2&nbsp;
Two determinant of MAPStroke volume, heart rate&nbsp;
<b>MAP Calculation</b>"<div><span style=""color: rgb(18, 134, 195);"">•</span><u><span style=""font-weight: bold;"">SBP </span></u><u><span style=""font-weight: bold;"">+</span></u><u><span style=""font-weight: bold;""> </span></u><u><span style=""font-weight: bold;"">2(DBP)</span></u></div>
<div><span style=""font-weight: bold;"">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;3</span></div>"
BP bladder width40% of circumference&nbsp;
<b>Too small BP</b>False high reading&nbsp;
<b>Too big BP cuff</b>False low reading&nbsp;
NIBP PhysicsKorotkoff sounds are auscultated during BP due to turbulent blood flow in at artery when the cuff is deflated. By comparing Korotkoff sounds, cuff pressure oscillations and palpating radial artery- arterial BP can be assessed&nbsp;<br>Correlation btw: first korotkoff sound, oscillation onset, and radial pulse wave
NIBP heightMAP decreases by 2mmHG every inch in elevation&nbsp;
NIBP supineHigher SBP, Lower DBP, Map is the same&nbsp;
BISEEG value- indicates sedation level&nbsp;
Over-sedating&nbsp;increased cost, delayed weaning, increased length of stay, increased testing
Under-sedatingAnxiety, awareness and recall, PTSD, Increased paralytic&nbsp;
BIS rangesAwake- 80-100<br>Mod sedation- 80-60<br>General Anesthesia- 40-60<br>Deep sedation- 20-40
SQI of BISmeasures reliability of signal&nbsp;
EMG of BISsignal artifact from muscle activity in face and forehead
Falsely elevates BISKetamine and N2O&nbsp;
WHen is a BIS requiredTIVA case
EKG leadsLeads II and V
Lead IIP wave, detects arrythmia
Lead VDetects ischemia&nbsp;
Modified V5 usedOnly 3 leads (black lead to V5 and monitor in I)
Leads to increased artifact?Cautery&nbsp;
<b>Lead Placement&nbsp;</b>Beware of surgical field, may need to tape down or use back of patient&nbsp;
Precordial Stethoscope (<b>Wenger </b>chest piece)Bell shaped, placed on suprasternal notch. Adhesive disks seal to patients skin. Earpiece allows user to listen to both the patient and the surroundings at the same time.&nbsp;
Most common place to listen with precordial stethescope4th intercostal space, left sternal border (nipple line)&nbsp;<br>Other: upper border of sternum, 2nd intercostal space, esophagus&nbsp;
Precordial stethoscope usesConfirm ventilation, breath sounds, heart sounds.&nbsp;<br><b>Not intended to substitute for 5 point auscultation to confirm ETT placement&nbsp;</b>
Temperature monitoring modalitiesSKin- convenient and noninvasive. Unreliable, liquid crystal temp monitor&nbsp;
<b>Tympanic temperature monitor&nbsp;</b>Core body, could rupture TM. tolerated in awake patients&nbsp;
<b>Nasopharynx temperature</b>Core temperature, inaccurate if awake/ nose breathing, can cause trauma
Distal Esophagus temperatureCore body, accurate (not open thoracic cases), potantial for trauma
Pulmonary artery tempCore body, accurate, invasive, not reliable in open chest
Bladder tempCore body, accurate- UTI risk&nbsp;
Gold standard for measuring tempPulmonary arterial blood&nbsp;<br>Correlates with: tympanic, distal esophagus, nasopharyngeal
Neuromuscular monitoringrecommended when paralyzing, helps avoid overparalyzing&nbsp;
Complications of residual paralysis (overparalyzing)airway complications and aspiration in PACU&nbsp;
Qualitative NMB monitoring&nbsp;Peripheral nerve stimulator
Quantitative NMB monitoring&nbsp;--myography
NM Monitoring sites- WristUlnar nerve (adductor policis muscle)<br>Negative electrode (black): wrist line, 1-2 cm over skin crease<br>Positive electrode (red): 2-3 cm proximal&nbsp;<br>Response: adduction of the thumb&nbsp;
Last to return muscleupper airway&nbsp;
NM monitoring site (orbicularis oculi or Corrugator Supercilii)&nbsp;Used in edema, reflective of the diaphragm and laryngeal muscles&nbsp;<br>Last to be paralyzed by NMBA and first to come back&nbsp;
Which muscles to monitorMost resistant- Orbicularis Oculi&nbsp;<br>Most sensitive- Adductor pollicis&nbsp;
Most sensitive muscle&nbsp;Eye muscles: Orbicularis oculi then Corrugator Supercilli&nbsp;
Muscle sensitivity- most sensitive to most resistant&nbsp;Eyes, extremities, trunk, abdominal muscles, diaphragm&nbsp;
Recovery PatternDiaphragm--&gt; abdomen--&gt; trunk--&gt; extremities
Recovery best measured in&nbsp;Hand- more sensitive than diaphragm, recovers at the same time as the larynx and airway&nbsp;
Blood flow and paralyticsHigher doses of drugs needed in aread with greater blood flow (head, neck, and diaphragm)&nbsp;
Fadeinability of a muscle to maintain response when repeatedly stimulated -- sign of drug-induced muscle paralysis when using NMB agents&nbsp;
Normal Response (muscle response)&nbsp;Positive Feedback: Presynaptic ACh receptors facilitate ACh release, maintaining muscle response during high impulse rates of nerve stimulation
Abnormal response (muscle stimulation- fade)NMB agents interfere with the positive feedback mechanism, blocking ACh receptors- leading to fade&nbsp;<br>-- causes the expected paralysis when using NMB agents&nbsp;
Single twitch&nbsp;Brief muscle contraction induced at a frequency of 0.1 to 1 hz for 0.1 to 0.2 ms&nbsp;<br>Administered regularly ( q 1 sec or q 10 sec)&nbsp;<br>Done to compare response prior to and following NMB agents&nbsp;
Single twitch- indicates onset of paralysisMuscle response to a single twitch begins to decrease<br>100% paralysis= no muscle response&nbsp;
Train of Four4 seperate stimuli every 0.5 second at 2hz for 2 seconds<br>Comparison of 4 twitches, leads to a progressive fade&nbsp;
Quantitative monitor of TOFt4:T1 ratio
TOF countAbsent t4- 75-80%<br>Absent T3- 80-85%<br>Absent T2- 90-95%<br>Absent T1- 100%
Double burst stimulation&nbsp;2 short bursts of a 50 hz tetanus seperated by 0.75 seconds&nbsp;<br>detects residual paralysis<br>Fade of D2- significant paralysis&nbsp;
Tetanus50-100 hz sustained tetanic stimulation over 5 seconds- resultin gin a single sustained contraction (70-75% blocked)&nbsp;<br>Sustained every 5 seconds- adequate but not complete recovery&nbsp;<br>fade present- significant block remains&nbsp;
&nbsp;Post Tetanic CountUsed when no response to other tests and pt has 100% paralysis. Provides estimatation for recovery time.&nbsp;
How to perform PTC50 hz applied every 5 seconds, followed by 3 second pause, then a single twitch at 1hz are delivered every second&nbsp;<br>Counting number of twitches post-tetanic count- gauge degree of paralysis and estimated recovery time
Quantitative NMT"<img src=""paste-db7d19cb0362d556de384e7d5c8e25de3c8ff704.jpg""><br>Baseline<br>Fade with NMDA<br>Complete NMB<br>Return of 2 twitches&nbsp;"
Neuromuscular transmission- how it works&nbsp;"<img src=""paste-452c30e20bf70308e265431c855a1057bbf22278.jpg"">"
Arterial Line componentsConnects intra-artery to external transducer<br>Rigid tubing (under 4 ft)<br>minimized stop cocks<br>Pressure bag &gt; 300mmhg with drip flush at 3-5 cc/hr<br>Zero right atrium or tragus&nbsp;
Indications for Art lineease of access<br>cont BP monitoring<br>critically ill patient<br>expected high EBL<br>frequent arterial samplings needed<br>Intropic or vasoactive drugs<br>controlled hypotension&nbsp;
Allen's test&nbsp;Test for collaterol blood flow<br>+- does not have adequate blood flow&nbsp;
How to perform Modified Allens test"<img src=""paste-acdc39f8899c561286cdb7689671334c8cc46525.jpg""><br><img src=""paste-f14244a44a3c1f59b9c31eee91301aa831c718ed.jpg"">"
Art line equiptment&nbsp;"<div>•20g
angiocath/arrow</div>
<div>•Armboard with
rolled gauze taped</div>
<div>•Chlorhexidine
prep</div>
<div>•Transparent
dressing</div>
<div>•1%
lidocaine in TB syringe</div>
<div>•STERILE
gloves, glasses</div>
<div>•Transducer
setup</div>
<div>•Ultrasound
and gel (POCUS)</div>"
Art Line placement&nbsp;"<div>Secure Arm on armboard - dorsiflexed&nbsp; with roll under wrist</div>
<div>Palpate radial artery, use ultrasound w
gel to identify location</div>
<div>Local (skin wheel) injection if patient
awake</div>
<div>Disinfect using Chlorprep allow to dry</div>
<div>put on glasses/eye protection</div>
<div>Prepare sterile area, use sterile gloves </div>
<div>Have connector tubing ready and gauze
nearby</div>
<div>Insert catheter at 45 degrees</div>
<div>Advance till flash, then change angle to
30 degrees and advance catheter over needle</div>
<div>Remove needle, connect to transducer</div>
<div>Place transparent dressing over site</div>"
Art line complicationsAccidental drug admin, thrombosis, avoid vigorous flushing<br>May cause damage, spasm, or aneurysm in vessel wall&nbsp;
Arterial Waveform&nbsp;"<img src=""paste-286e7380d80502e0b2bfdf8a30ecefa7edbf2711.jpg""><br>Reflects the pressure generated in the arteries following ventricular contraction&nbsp;"
CVP indicationsFluid status, measure CVP, poor venous access, admin of drug irritants, parental feeding
Central Line veinsRight and Left IJ, Right and Left Subclavian, femoral
<b>PICC vein&nbsp;</b>Inserted via the AC veins - basilic vein is the best and advanced into central veins&nbsp;
Complications of CVPMalpositioned, hematoma, arterial puncture, pneumothorax, hemorrhage, sepsis, air emboli, catheter embolism, thrombosis, hemothorax, cardiac temponade, and cardiac arrythmias&nbsp;
Why trendelenbergIncrease pressure in vessels, ensuring they are greater than atmospheric pressure (prevent emboli)&nbsp;<br>- Also leads to engorgement&nbsp;
What is central venous pressurePressure in the superior vena cava or right atrium&nbsp;
CVP used forassess cardiac function, circulating blood volume, vascular tone, and response to treatment&nbsp;
Normal CVP MeasurementsMid Axilla: 0-8
Cause low CVPtachycardia, hypotension, low UO<br>hypovolemia
Treat low CVPfluid challenge&nbsp;
Cause high CVPPulmonary crepitus, tachycardia, heptomegaly, ascites, peripheral oedema, venous congestion and dilation<br>Heart failure, cardiac tamponade, tension pneumo
Treat high CVPdiuretics, treat underlying condition&nbsp;
CVP waveform"<img src=""paste-16ed48da8e5f7b70c04acac3aa629a1ad69364d9.jpg""><br><img src=""paste-a7d7591493be56d9cca8dc588d785965bf4e03b8.jpg""><br>A wave- atrial contraction&nbsp;"
Pulmonary Artery Catheter Indications&nbsp;Cardiac surgery, massive trauma, poor LV fx, assessing intravascular volume, evaluate fluid resusitation, admin vasoactive agents, valvular heart disease&nbsp;
Pulmonary Artery Catheter Waveform"<img src=""paste-352531cabbd62b8851e8d7fa152e407bbb7be893.jpg"">"
Pulmonary artery wedge pressure&nbsp;PAWP is like a snapshot of pressure in a crucial part of your heart-lung system.<br>6-12
Normal pulmonary artery systolic pressure (right ventricle)15-30
Normal diastolic pulmonary artery pressure&nbsp;5-15
Mean pulmonary artery pressure (MPAP)10-20
Transesophageal EchocardiogramMonitor cardiac function and diagnose venous air embolism
HemacueMonitor blood loss and hemoglobin values
ACTmonitor heparinization during cardiac and vascular surgeries&nbsp;
epoc BGEM test card measurespH, pCO2, pO2, Na, K, Ca, Glu, Lac, Hct
BGEM calculatescTCO2, cHCO3, BE(ecf), BE(b), cSO2, cHgb
Cerebral oximetrya method to measure the amount of oxygen in the brain<br>Used to prevent cerebral ischemia&nbsp;<br>sampling is derived from both SaO2 and SvO2&nbsp;
Increased StO2 cerebral oximetryHigh SaO2, High HGB, High PaCO2, decreased temp, increased sedation, increased MAP, increased CO
<b>Physiological factors increasing Cerebral O2 delivery&nbsp;</b>Cerebral blood flow: PaCO2, MAP, CO<br>Hemoglobin<br>SaO2/ spO2
<b>Physiological factors: Cerebral O2 consumption</b>Cerebral metabolic rate (CMRO2): Increased Temperature, decreased anesthesia&nbsp;
Benefits of cerebral oximetrylower stroke risk, renal failure, respiratory failure, surgical complications&nbsp;<br>Guide controlled hypotension<br>modify therapies<br>determine need for blood transfusion<br>assess hemodilution<br>detect flow obstructions and other trends towards ischemia&nbsp;