Presenter: Dr. James Supervisor: Dr. Shareena

1. Presenter: Dr. JamesSupervisor: Dr. Shareena Standard Monitoring in Anaesthesia

2. OLD IS GOLD!!

3. Monitoring: A Definition • ... interpret available clinical data to help recognize present or future mishaps or unfavorable system conditions • ... not restricted to anesthesia (change “clinical data” above to “system data” to apply to aircraft and nuclear power plants)

4. Aim?

5. What do you mean by that ? • Safety of the Anaesthetist ? • Safety of the Surgeon ? • Safety of the Patient ?

7. Where Safety Starts ? Patient Surgeon’s Skill Facilities, Equipment, and Medications Anaesthetist’s Skill

8. Survival Depends....... Referal 10% HELP 10% 20% Anaesthetist Skill 60% Facilities, Equipment, and Medications Quantity and Quality

9. Where Safety Starts ? Patient - Optimized patient (CVS, RS, Renal, Liver) - ASA risk - Well controlled Hypertension - Well controlled Diabetes - Haemodynamicallystabilised

10. Medication • All drugs should be clearly labelled • The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected • Ideally drugs should be drawn up and labelled by the anaesthetist who administers them.

11. Anaesthetist Skill • Learn one or two alternate method of Airway skill • Practice it in routine cases

12. Anaesthesia does not deliver any direct therapeutic benefit. • The risks of anaesthesia must therefore be as low as possible. • Anesthesiology has been identified as a leader in improving patient safety

13. Anaesthesia-related mortality • end of the 19th century, 1/900 patients died • late 1950s, 3.1/10 000 to 6.4/10 000 died • Last 3 decades, 0.04–7 per 10 000 died Haller G. et al (2011)

14. Anaesthesia-related morbidity • Minor morbidity: • Moderate distress without prolongation of hospital stay or permanent sequelae (e.g., postoperative nausea and vomiting (PONV) • Intermediate morbidity: • Serious distress or prolongation of hospital stay, or both, without permanent sequelae (e.g., dental injury). • Major morbidity: • Permanent disability and sequelae (e.g., spinal cord injury).

16. Causes of mortality and morbidity • Suboptimal care related to inadequate patient evaluation or incorrect preoperative management, has been found to be a major contributing factor in 38–42% of deaths. Gibbs N et al (2005), Lienhart A et al (2006)

17. Causes of mortality and morbidity • Postoperative respiratory depression, suboptimal management of postoperative blood loss, insufficient supervision or inadequate resuscitation still contribute to 43% of anaesthesia-related deaths. Lienhart A et al (2006)

18. Causes of mortality and morbidity • Human error/failures • 51–77% of anaesthesia-related deaths • lack of experience or competence , 89% • errors of judgement or analysis, 11% • fatigue Lienhart A et al (2006)

19. Peri-anaesthetic care and monitoring standards • Pre-anaesthetic care • Pre-anaesthesia checks • Monitoring during anaesthesia

20. Pre-anaesthesia checks PRE ANAESTHETIC CHECK LIST Patient name ________________ Number ___________ Date of Birth ­__/__/__ Procedure____________________________________ Site_______

23. Level of monitoring • Routine / Specialize / Extensive • Non-equipment / Non-invasive / Minimally invasive / Penetrating / Invasive / Highly invasive • Systematic • Respiratory / Cardiovascular / Temperature/Fetal • Neurological / Neuro-muscular / Volume status & Renal • Standards for basic intraoperative monitoring ( ASA)

24. Standards for basic intraoperative monitoring ( ASA : American Society of Anesthesiologists) Standard I • Qualified anesthesia personnel shall be present in the room throughout the conduct of all GA, RA, MAC Standard II • During all anesthetics, the patient’s respiratory (ventilation, oxygenation), circulation and temperature shall be continually evaluated

25. Monitoring in the Past • Visual monitoring of respiration and overall clinical appearance • Finger on pulse • Blood pressure (sometimes)

26. Monitoring in the Past Finger on the pulse

27. Harvey Cushing Not just a famous neurosurgeon … but the father of anesthesia monitoring • Invented and popularized the anesthetic chart • Recorded both BP and HR • Emphasized the relationship between vital signs and neurosurgical events( increased intracranial pressure leads to hypertension and bradycardia )

28. Monitoring during anaesthesia • Oxygenation • Airway and ventilation • Circulation • Temperature • Neuromuscular function • Depth of anaesthesia • Audible signals and alarms

29. Examples of Multiparameter Patient Monitors

30. Transesophageal Echocardiography Depth of Anesthesia Monitor Evoked Potential Monitor Some Specialized Patient Monitors

32. Available audible signals (pulse tone of the pulse oximeter) and audible alarms (with appropriately set limit values) should be activated at all times and loud enough to be heard throughout the operating room

33. RECOMMENDATIONS I. Clinical Monitoring by an Anaesthesist 1.1 All anaesthetics should be administered by a registered medical practitioner who has received sufficient training in anaesthesiology and resuscitation.1.2 Skilled assistance for the anaesthesiologist must be available at all times during the conduct of the anaesthesia. 1.3 Professional care of the patient during anaesthesia requires the continous presence of the anaesthesiologist throughout the anaesthetic. The presence of a skilled assistant is no substitute for the anaesthetist. 1.4 The anaesthesiologist must provide an adequate and legible record of the anesthetic and this must be part of the patients medical records.1.5 It is the responsibility of the anaesthesiologist to ensure that all equipment used for the administration of anaesthesia is correctly functioning before the start of each anaesthetic.

34. II. Monitoring Equipment 2.1 Oxygen analyser2.2 Breathing system disconnection or ventilator failure alarm2.3 Pulse oximeter2.4 Electrocardiograph 2.5 Intermittent non-invasive blood pressure monitor2.6 Carbon dioxide monitor 2.7 Volatile anaesthetic agent concentration monitor2.8 Temperature monitor2.9 Continuous invasive blood pressure monitor 2.10 Neuromuscular function monitor2.11 Monitoring of anaesthetic effect on the brain2.12 Other equipment

35. Cardiovascular monitoring • Routine monitoring • Cardiac activity • Non-invasive blood pressure ( NIBP ) • Electrocardiography ( ECG ) • Advanced monitoring • Direct arterial blood pressure • Cardiac filling pressure monitor • Central venous pressure • Pulmonary capillary wedge pressure

36. Cardiovascular monitoring • Electrocardiography • Cardiac activity • Arrhythmia: Lead II • Myocardial ischemia • Electrolyte imbalance • Pacemaker function

37. Cardiovascular monitoring • Non-invasive blood pressure (NIBP) • Cuff: width 120-150 % limb diameter, air bladder includes more than halfway around limb • Manometer: aneroid, mercury • Detector: manual, automated

38. Cardiovascular monitoring • Non-invasive blood pressure • Inaccurate: cuff size, inflated pressure, shivering, cardiac arrhythmia, severe vasoconstriction Proper application Narrow cuff Loose cuff

39. Cardiovascular monitoring • Direct arterial pressure monitor • Indications • Continuous blood pressure monitor: anticipated cardiovascular instability, direct manipulation of cardiovascular system, inability to accurate measurement directly • Frequent arterial blood sampling: ABG, Acid-base / electrolyte / glucose disturbance, Coagulopathies

40. Cardiovascular monitoring • Direct arterial pressure monitor • Contraindications • Local infection • Impaired blood circulation: Raynaud’s phenomenon, DM • Risks of thrombosis: hyperlipidemia, previous brachial artery cannulation • Modified Allen’s test ???

41. Cardiovascular monitoring • Direct arterial pressure monitor • Complications • Direct trauma: AV-fistula, Aneurysm • Hematoma • Infections • Thrombosis • Embolization • Massive blood loss

42. Respiratory monitoring • Ventilatory monitoring • Oxygenation monitoring • Machine and Circuit monitoring • Clinical skills • Monitoring devices

43. Ventilatory monitoring • Clinical skills • Direct observation: rate, rhythm, volume of respiration • Auscultation: precordial, esophageal stethoscope • Palpation: reservoir bag movement • Monitoring devices • Spirometer • Airway pressure manometer • Circuit disconnection alarm

44. Ventilatory monitoring • Capnometer(End-tidal CO2 analysis) • relationship with PaCO2 : ETCO2 < PaCO2 ~ 3-6 mmHg • mainly depends on dead space ventilation • normal value 30 – 35 mmHg • Infrared absorption spectrography • Main-stream VS. Side-stream

45. Ventilatory monitoring • Capnogram : normal curve • 1. Dead space air (no CO2) • 2. Mixed bronchus & alveolus air (CO2 upstroke) • 3. Alveolus air (CO2 plateau) Inspiration ETCO2 3 2 1

46. Ventilatory monitoring • Capnometer (End-tidal CO2 analysis) • Most useful in detection of Esophageal intubation, airway or circuit disconnection • Useful in CO2rebreathing, partial recovery of neuro-muscular blockade, good predictor of successful CPR

47. waveform of ET-CO2 • Capnograph -esophageal intubation -bronchial intubation -airway obstruction -circuit disconnect -circuit leakage -partial rebreathing -spontaneous breathing (recovary of neuromuscular blockade) -hypoventilation

48. Oxygenation monitoring • Clinical skills • Direct observation: impaired mental function, sympathetic overactivities, appearance(+ cyanosis) • Auscultation: wheezing, crepitation • Monitoring devices • Arterial blood gas analysis • Percutaneous O2 measurement • Pulse oximeter

49. Oxygenation monitoring • Pulse oximeter • SpO2correlates with PaO2 as in Oxygen-hemoglobin dissociation curve • SpO2 90 =PaO2 60 mmHg (moderate hypoxemia)

50. Oxygenation monitoring • Pulse oximeter artifacts • Abnormal hemoglobin: COHb, MetHb, HbF • Dye: Methylene blue • Anemia • Ambient light • Arterial saturation • Blood flow • Motion • Nail polish • Electro-cautery