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Physiologic Monitoring of the Surgical Patient . Basic Science Conference 1/26/2010. Background. Latin word monere , which means “to warn, or advise,” is the origin for the English word monitor.

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physiologic monitoring of the surgical patient

Physiologic Monitoring of the Surgical Patient

Basic Science Conference

1/26/2010

background
Background
  • Latin word monere, which means “to warn, or advise,” is the origin for the English word monitor.
  • Patients undergo monitoring to detect pathologic variations in physiologic parameters, in order to give us advance warning of deterioration of one or more organ systems.
  • GOAL: Use the information to make a timely intervention.
  • Monitoring also used to guide resuscitation and titrate medications.
background cont
Background (cont.)
  • The ultimate goal of hemodynamic monitoring is to ensure that the flow of oxygenated blood through the microcirculation is sufficient to support aerobic metabolism at the cellular level.
  • This involves multiple inputs.
  • Oxygen delivery
    • CO
    • Hgb
    • O2 sat
    • PAO2
arterial blood pressure
Arterial Blood Pressure
  • The pressure exerted by blood in the systemic arterial system.
  • Hypotension = Shock ?
  • MAP = CO x SVR
  • How do we measure blood pressure?
    • Non-invasive (cuff)
    • Invasive
      • Risks and benefits
noninvasive
Noninvasive
  • Manual and automated means, both of which use a cuff. The width of the cuff should be about 40% of the circumference.
  • Korotkoff sounds
    • Systolic- tapping sounds first audible
    • Diastolic- audible pulsations disappear
  • Dyna-map
invasive
Invasive
  • Fluid-filled tubing to connect an intra-arterial catheter to external strain-gauge transducer which is transduced as a continuous waveform.
  • Underdamped –systolic overestimated and diastolic underestimated
  • Overdamped- systolic underestimated and diastolic overestimated
  • Use Mean Arterial Pressure
  • Systolic pressure higher, diastolic pressure lower in the radial artery compared to the aorta
invasive complications
Invasive Complications
  • Thrombosis (Allen test)
  • Air Embolism
  • Infection
ekg monitoring
EKG monitoring
  • Continuous monitoring with three lead EKG
  • Immediate alarm with arrhythmias
  • Can detect ST elevation
  • No substitute for 12 lead EKG
cardiac output
Cardiac output
  • Determinants of Cardiac Performance
    • Preload - EDV
    • Afterload-SVR
    • Contractility- dependent on preload and afterload
pulmonary artery catheter
Pulmonary artery catheter
  • PAC has four channels
  • Balloon (1.5cc)
  • CVP, PA
  • Insertion
  • Waveforms
  • Distance
    • 45 cm RSCV
    • 50cm RIJ
    • 55cm LSC
    • 60cm LIJ
approximate normal ranges for selected hemodynamic parameters in adults
Approximate Normal Ranges for Selected Hemodynamic Parameters in Adults
  • CVP 0–6 mmHg
  • Right ventricular systolic pressure 20–30 mmHg
  • Right ventricular diastolic pressure 0–6 mmHg
  • PAOP 6–12 mmHg
  • Systolic arterial pressure 100–130 mmHg
  • Diastolic arterial pressure 60–90 mmHg
  • MAP 75–100 mmHg
  • QT   4–6 L/min
  • QT*  2.5–3.5 L·min–1·m–2
  • SV 40–80 mL
  • SVR 800–1400 dyne·sec·cm–5
  • SVRI 1500–2400 dyne·sec·cm–5·m–2
  • PVR 100–150 dyne·sec·cm–5
  • PVRI 200–400 dyne·sec·cm–5·m–2
hemodynamic measurements
Hemodynamic measurements
  • Cardiac output by thermodilution
  • Mixed venous oximetry
  • RV ejection fraction
types of shock
Types of Shock
  • Hemorrhagic
  • Septic
  • Cardiogenic
  • Neurogenic
  • Hypo adrenal
risks and benefits of pacs
Risks and benefits of PACs
  • Many studies show no mortality difference with PAC use and more complications related to the catheter or its placement.
  • Alternatives
    • Doppler Ultrasonography
    • Impedance cardiography
    • Pulse contour analysis
    • TEE
respiratory monitoring
Respiratory monitoring
  • The ability to monitor various parameters of respiratory function is of utmost importance is critically ill patients.
  • Arterial blood gases
  • Peak and plateau airway pressure
  • Pulse oximetry
  • CO2 monitoring
slide19
ABG
  • O2 (PEEP, FIO2)
  • CO2 (RR, TV)
  • O2 sat
  • HCO3
  • BE/BD
airway pressures
Airway Pressures
  • Increased pressure = decreased compliance
    • Hemo/pneumothorax
    • Atelectasis
    • Pulmonary edema
    • ARDS
    • Abdominal distension
  • Barotrauma
renal monitoring
Renal monitoring
  • Urine output
  • Bladder pressure
neurologic monitoring
Neurologic monitoring
  • Intracranial pressure
    • CPP= MAP- ICP
      • CPP>60
    • Allows monitoring and drainage
    • Strategies to decrease ICP
  • Transcranial doppler ultrasonography
  • EEG
  • Brain tissue oxygen tension
conclusions
Conclusions
  • Physiologic monitoring provides us with a multitude of information.
  • Determining what information is beneficial and using this to positively affect the outcome of the patient is the key.
all of the following are most often associated with a decrease in svo2 except
All of the following are most often associated with a decrease in SVO2 except:
  • Myocardial infarction
  • Cardiac tamponade
  • Hemorrhagic shock
  • Septic shock
slide25

You place a swan ganz catheter in a 709kg adult male through the left subclavian vein and get a wedge pressure. The approximate distance into the patient should be:

  • 45cm
  • 50cm
  • 55cm
  • 60cm
slide26

While trying to treat a patient with severe ARDS, you start to increase the PEEP to improve oxygenation. After doing this, you notice a decrease in urine output. The mechanism of decreased urine output with increased PEEP is:

  • Compartment syndrome
  • Decreased cardiac output
  • Reduced oxygenation
  • Retained CO2
slide27
A patient stops making urine after surgery. All of te following values are consistent with pre-renal renal failure except:
  • Urine Na 5
  • BUN/Cr ratio >35
  • FeNA=0.1%
  • Urine osmolality 200 mOsm
all of the following concerning pulmonary artery catheters are true except
All of the following concerning pulmonary artery catheters are true except:
  • Excessive PEEP can artificially increase wedge pressure.
  • Excessive PEEP can artificially decrease wedge pressure.
  • Zone III of the lung is the optimal site of placement.
  • The balloon should be inflated when advancing the catheter.
slide29
A critical care patient has the following PAC values: CI 1.8, SVR 3000, and a wedge pressure of 5. This is most consistent with:
  • Septic shock
  • Hypovolemic shock
  • Cardiogenic shock
  • Neurogenic shock
slide30
A critical care patient has the following PAC values: CI 5.0, SVR 500, and a wedge pressure of 7. This is most consistent with:
  • Septic shock
  • Hypovolemic shock
  • Cardiogenic shock
  • Neurogenic shock
slide31
A critical care patient has the following PAC values: CI 1.8, SVR 3000, and a wedge pressure of 28. This is most consistent with:
  • Septic shock
  • Hypovolemic shock
  • Cardiogenic shock
  • Neurogenic shock
slide32
A critical care patient has the following PAC values: CI 2.0, SVR 500, and a wedge pressure of 5. This is most consistent with:
  • Septic shock
  • Hypovolemic shock
  • Cardiogenic shock
  • Neurogenic shock
slide33

A patient with ARDS following an inhalation injury has an oxygenation saturation of 90% on 90% FiO2 with an SVO2 of 55. The patient’s ABG is pH 7.35, pO2 of 60, and pCO2 60. The patient has a cardiac output of 5, and a Hgb of 8. Oxygen delivery will increase the most by:

  • Increasing cardiac output by 1
  • Increasing hemoglobin by 2
  • Increasing FiO2 by 10%
  • Decreasing CO2 by 10%
  • Oxygen delivery = CO x[(Hgb x1.34x O2 sat) + (0.003x PaO2)]