Transcript Monitoring

Standard
Monitoring
in
Anaesthesia
Presenter: Dr. James
Supervisor: Dr. Shareena
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)
Aim?
What do you mean by that ?
• Safety of the Anaesthetist ?
• Safety of the Surgeon ?
• Safety of the Patient ?
Where Safety Starts ?
Patient
Facilities, Equipment, and Medications
Surgeon’s Skill
Anaesthetist’s Skill
Survival Depends.......
Referal
10%
HELP
10%
20%
Anaesthetist Skill
60%
Facilities, Equipment, and Medications
Quantity and Quality
Where Safety Starts ?
Patient
- Optimized patient (CVS, RS, Renal, Liver)
- ASA risk
- Well controlled Hypertension
- Well controlled Diabetes
- Haemodynamically stabilised
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.
Anaesthetist Skill
• Learn one or two alternate method of Airway
skill
• Practice it in routine cases
• 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
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)
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).
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)
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)
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)
Peri-anaesthetic care and
monitoring standards
• Pre-anaesthetic care
• Pre-anaesthesia checks
• Monitoring during anaesthesia
Pre-anaesthesia checks
PRE ANAESTHETIC CHECK LIST
Patient name ________________ Number ___________ Date of Birth __/__/__
Procedure____________________________________ Site_______
Check patient
risk factors
Check resources
(if yes - circle and
annotate)
ASA 1 2 3 4 5 E
Airway
Mallampati (pictures)
Aspiration risk?
Allergies?
Abnormal
investigations?
Medications?
Co-morbidities?
Airway
N
N
N
N
N
Present and
Functioning
Masks
Airways
Laryngoscopes (working)
Tubes
Bougies
Breathing
Leaks (a FGF of 300 ml/minute
maintains a pressure of > 30 cm H2O) -
Check patient
risk factors
(if yes - circle and
annotate)
ASA 1 2 3 4 5 E
Airway
Mallampati (pictures)
Aspiration risk?
Allergies?
Abnormal
investigations?
Medications?
Co-morbidities?
Check resources
Present and
Functioning
Soda lime (colour - if present)
Circle system (2-bag test if present)
Suction
Drugs and Devices
Oxygen cylinder (full and off)
Vaporisers (full and seated)
Drips (IV secure)
Drugs (lebeled - TIVA connected)
Blood / fluids available
Monitors - alarms on
Humidifiers, warmers and
thermometers
Emergency
Assistant
Adrenaline
Suxamethonium
Self inflating bag
Tilting table
-
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)
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
Monitoring in the Past
• Visual monitoring of
respiration and
overall clinical
appearance
• Finger on pulse
• Blood pressure
(sometimes)
Monitoring in the Past
Finger on the pulse
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 )
Monitoring during anaesthesia
•
•
•
•
•
•
•
Oxygenation
Airway and ventilation
Circulation
Temperature
Neuromuscular function
Depth of anaesthesia
Audible signals and alarms
Examples of Multiparameter Patient Monitors
Transesophageal
Echocardiography
Depth of Anesthesia Monitor
Evoked Potential Monitor
Some Specialized Patient Monitors
Oxygenation
Oxygen supply :
HIGHLY
RECOMMENDED
RECOMMENDED
- Supplemental oxygen
-Un interrupted supply
- Inspired oxygen concentration
- Visual examination,
Airway and
ventilation
- Observation
- Auscultation
- The reservoir bag
-Capnography
- Precordial,
- Pretracheal, or
-Oesophageal stethoscope
-Palpation of the pulse
- Auscultation of the
heart sounds
- Pulse oximetry
- Electrocardiograph
- Clinical examination
- Pulse oximetry
- Capnography
- At least every 5 mts
- NIBP
Circulation
Cardiac rate and
rhythm :
Tissue perfusion :
Blood pressure :
-
- Oxygen supply failure alarm
-Hypoxic Guard
Oxygenation of
the patient :
- Adequate illumination
- Pulse oximetry
SUGGESTED
--
- Continuous
measurement of the
inspiratory and/or
expired gas volumes,
and of the
concentration of
volatile agents
- Defibrillator
- IABP
Temperature
HIGHLY
RECOMMENDED
RECOMMENDED
- At frequent intervals
- Continual electronic
temperature measurement
Neuromuscular
function
Depth of anaesthesia
Audible signals and
alarms
SUGGESTED
- Peripheral nerve
stimulator
- Degree of
- Continuous measurement
- BIS Monitor
unconsciousness (clinical of the inspiratory and/or
observation)
expired gas volumes, and of
the concentration of volatile
agents
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
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.
II. Monitoring Equipment
2.1 OXYGEN ANALYSER
2.2 BREATHING SYSTEM DISCONNECTION OR VENTILATOR FAILURE ALARM
2.3 PULSE OXIMETER
2.4 ELECTROCARDIOGRAPH
2.5 INTERMITTENT NON-INVASIVE BLOOD PRESSURE MONITOR
2.6 CARBON DIOXIDE MONITOR
2.7 VOLATILE ANAESTHETIC AGENT CONCENTRATION MONITOR
2.8 TEMPERATURE MONITOR
2.9 CONTINUOUS INVASIVE BLOOD PRESSURE MONITOR
2.10 NEUROMUSCULAR FUNCTION MONITOR
2.11 MONITORING OF ANAESTHETIC EFFECT ON THE BRAIN
2.12 OTHER EQUIPMENT
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
Cardiovascular monitoring
• Electrocardiography
– Cardiac activity
– Arrhythmia: Lead II
– Myocardial ischemia
– Electrolyte imbalance
– Pacemaker function
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
Cardiovascular monitoring
• Non-invasive blood pressure
– Inaccurate: cuff size, inflated pressure, shivering,
cardiac arrhythmia, severe vasoconstriction
Proper application
Narrow cuff
Loose cuff
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, Acidbase / electrolyte / glucose disturbance,
Coagulopathies
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 ???
Cardiovascular monitoring
• Direct arterial pressure monitor
– Complications
• Direct trauma: AV-fistula, Aneurysm
• Hematoma
• Infections
• Thrombosis
• Embolization
• Massive blood loss
Respiratory monitoring
• Ventilatory monitoring
• Oxygenation monitoring
• Machine and Circuit monitoring
– Clinical skills
– Monitoring devices
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
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
Ventilatory monitoring
• Capnogram : normal curve
– 1. Dead space air (no CO2)
– 2. Mixed bronchus & alveolus air (CO2 upstroke)
– 3. Alveolus air (CO2 plateau)
2
1
3
Inspiration
ETCO2
Ventilatory monitoring
• Capnometer (End-tidal CO2 analysis)
– Most useful in detection of Esophageal intubation,
airway or circuit disconnection
– Useful in CO2 rebreathing, partial recovery of neuromuscular blockade, good predictor of successful CPR
waveform of ET-CO2
• Capnograph
-esophageal intubation
-bronchial intubation
-airway obstruction
-circuit disconnect
-circuit leakage
-partial rebreathing
-spontaneous breathing (recovary of neuromuscular blockade)
-hypoventilation
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
Oxygenation monitoring
• Pulse oximeter
– SpO2 correlates with PaO2
as in Oxygen-hemoglobin
dissociation curve
– SpO2 90 = PaO2 60 mmHg
(moderate hypoxemia)
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
Machine & circuit monitoring
• Safety system
– DISS, PISS, Quick disconnection adaptor
– Oxygen fail-safe valve, Oxygen supply failure alarm
• Oxygen analyzer
• Airway gas composition
– Clinical skills: flowmeters, vaporizers
– Monitoring devices: Infrared spectrometer
Depth of Anesthesia
• Clinical Signs
– eye signs
– respiratory signs
– cardiovascular signs
– CNS signs
• EEG monitoring
• Facial EMG monitoring (experimental)
• Esophageal contractility (obsolete)
Neurologic monitoring
– Depth of anesthesia ( BIS )
– EEG
– Evoked potentials
– Cerebral blood flow
– Intracranial pressure
Neuromuscular monitoring
– Clinical skills
– Monitoring device :
Volume status and renal monitoring
– Estimate blood loss
– Urine output
– Hemodynamic stability
Electrolyte / Metabolic monitoring
•
•
•
•
Fluid balance
Sugar
Electrolytes
Acid-base balance
Temperature monitoring
– 4 mechanism of heat loss
– Perioperative hypothermia (BT<36)
– Core temperature : nasopharynx, esophageal,
tympanic membrane, pulmonary a. catheter, bladder,
rectum
Temperature Monitoring
Rationale for use
• detect/prevent hypothermia
• monitor deliberate hypothermia
• adjunct to diagnosing MH
• monitoring CPB cooling/rewarming
Temperature monitoring
– Deleterious effects of hypothermia
-cardiac dysrhythmia
-increased PVR
-Lt. shift of the Oxygen-hemoglobin dissociation curve
-reversible coagulopathy (platelet dysfunction)
-postoperative protein catabolism and stress response
-altered mental status
-impaired renal function
-decreased drug metabolism
-poor wound healing
CONCLUSION
• Vigilance in OT cannot be over-emphasized
• Technology does not guarantee safety and
accuracy
• Monitor with purpose
• Record and Communicate the findings
• Respond to findings
Thank you