Patient Monitors

1
Patient Monitors

• R1 ???

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vigilance

• The motto of the American Society of
  Anesthesiologists

3

• CARDIAC MONITORS
• Arterial Blood Pressure
• Electrocardiography
• Central Venous Catheterization
• Pulmonary Artery Catheterization
• Cardiac Output
• PULMONARY MONITORS
• Precordial Esophageal Stethoscopes
• Pulse Oximetry
• Capnography
• Anesthetic Gas Analysis
• NEUROLOGICAL SYSTEM MONITORS
• Electroencephalography
• Evoked Potentials
• MISCELLANEOUS MONITORS
• Temperature
• Urinary Output
• Peripheral Nerve Stimulation

4
Arterial Blood Pressure

• Pulse pressure
• systolic pressures ? diastolic pressures
  ? ??
• Mean Arterial Pressure
• The time-weighted average of arterial
  pressures during a pulse cycle
• MAP (SBP) 2 (DBP) / 3
• ?? ??? ?? ? ??? ??
• ??? ???? ??? ?? ??? ??
• 1cm 0.74mm Hg

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Noninvasive Arterial Blood Pressure Monitoring

• Indications
• ?? ??
• Contraindications
• in extremities with vascular abnormalities
  or with intravenous lines
• Techniques
• a. Palpation
• b. Doppler Probe
• c. Auscultation
• d. Oscillometry
• e. Arterial Tonometry

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Noninvasive Arterial Blood Pressure Monitoring

• Palpation
• cuff? ???? ??? ?? ????? cuff pressure? ??
• ?? systolic pressure?? ?? ?? ?? ??
• diastolic pressures? MAP? ?? ???
• Doppler Probe
• ??? ?? doppler probe? ?? red blood cell
  ? ???? ??
• obese patients, pediatric patients,
  patients in shock? ??
• systolic pressures ? ?? ??
• Auscultation
• Kortokoff sounds? ??
• cuff pressure? systolic? diastolic
  pressure??? ????? turbulent flow

7
Noninvasive Arterial Blood Pressure Monitoring

• Oscillometry
• arterial pulsations ? ??? ??
• cuff pressure? systolic pressure ???? ???
  cuff??? ??
• ??? MAP?? ?? ??
• ???? ???? ??? ? ? ??
• ?? ???? noninvasive blood pressure
  monitors

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Noninvasive Arterial Blood Pressure Monitoring

• Arterial Tonometry
• pressure transducers? ??? ??? ???? ??
• invasive arterial blood pressure? ???
  waveform ????
• ???? ??? ??
• ??? ???? ??? ?? calibration? ??

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Noninvasive Arterial Blood Pressure Monitoring

• Clinical Considerations
• ??? vital organ??? ??? ??? ??? ????? ?
• arterial blood flow? ???? ???? ??
• but, ??? ????? ? ?? ??
• ( ? Flow Pressure / Resistance )
• ??? cuff size? ??
• ?????? ?? ?? ??? nerve palsy, ???? ???
  fluid? extensive extravasation? ??

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Invasive Arterial Blood Pressure Monitoring

• Indications
• - induced hypotension
• - wide blood pressure swings? ???? ??
• - ??? blood pressure? ??? end-organ disease
• - ???? arterial blood gas analyses? ??? ??
• Contraindications
• - collateral blood flow? ?? ??
• - preexisting vascular insufficiency (eg,
  Raynauds phenomenon)

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Invasive Arterial Blood Pressure Monitoring

• Selection of Artery for Cannulation
• a. Radial artery (most common)
• - superficial? ??
• - collateral flow? ??
• - 5?? ???? collateral blood flow
• - Allens test
• b. Ulnar artery
• - deeper and more tortuous
• - ? ???? ??

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Invasive Arterial Blood Pressure Monitoring

• Selection of Artery for Cannulation
• c. Brachial artery
• - less waveform distortion
• - kinking? ???
• d. Femoral artery
• - excellent access
• - infection
• - arterial thrombosis
• e. Dorsalis pedis and Posterior tibial
  arteries
• - most distorted waveforms
• f. axillary artery
• - ?? axillary nerve plexus damage ( ?
  hematao or traumatic cannulation)
• - air ? thrombi? cerebral circulation ??
  ?? ???

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Invasive Arterial Blood Pressure Monitoring

• Technique of Radial artery cannulation
• - the pressure-tubing-transducer system?
• heparinized saline ??
• - ??? supination and extension ?? ??
• - radial pulse ?? (with 2nd and 3rd fingers)
• - skin preparation (with a bactericidal
  agent)
• - local anesthetic ?? (with 25G needle)
• - 45? ??? ????? ?? ?? (with 20 or 22G
  catheter)
• - Blood flashback? ???? needle? 30?? ???
• 1-2mm ? ??
• - catheter? vessel lumen?? ??
• cathter? spinning ???? ??
• - 3rd and 4th fingers? proximal?? ??? ??
• ??? ??
• - tubing? catheter??
• - water-proof tape??? ??

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Invasive Arterial Blood Pressure Monitoring

• Complications
• - hematoma
• - bleeding
• - vasospasm
• - arterial thrombosis
• - embolization of air bubbles or thrombi
• - necrosis of skin
• - nerve damage
• - infection
• - loss of digits
• - unintentional intraarterial drug
  injection

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Invasive Arterial Blood Pressure Monitoring

• Complications? ????
• - prolonged cannulation
• - hyperlipidemia
• - ?? ?? ?? ??
• - female
• - extracorporeal circulation
• - vasopressors ? ??

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Invasive Arterial Blood Pressure Monitoring

• Clinical Considerations
• - ???? blood pressure measurement? ??
• - ??? ???? zeroing
• - ???? zeroing ??
• - arterial waveform????? ??
• the rate of upstroke ? contractility
• the rate of downstroke ? peripheral
  vascular resistance
• respiratory cycle??? size? ??? ?? ?
  hypovolemia
• - ???? arterial blood gas sampling ??

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Electrocardiography

• Indications Contraindications
• - all patients, no contraindications
• Techniques Complications
• - lead ? atrial axis ? ???? ???
• ?? ? P wave? ???
• arrhythmias, inferior wall
  ischemia ? ??
• - modified V5 anterior and lateral wall
  ischemia ? ??

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Electrocardiography

• Clinical Considerations
• - Usage
• - arrhythmias
• - myocardial ischemia
• - conduction abnormalities
• - pacemaker malfunction
• - electrolyte disturbances
• - Limitation
• - patient or lead-wire movement
• - electrocautery? ??
• - faulty electrodes

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Electrocardiography

• Clinical Considerations
• - preinduction rhythm strip? intraoperative
  tracings? ??
• - 1mV ? signal? 10mm ? ??? standardization
• - Criteria for diagnosing myocardial
  ischemia
• 1mm??? flat or downsloping ST-segment
• J point(the end of the QRScomplex)? ??
  60ms ??
• particularly in conjunction with T
  wave inversion
• - ST segment elevation with peak T waves can
  also present ischemia
• - WPW syndrome, bundle branch blocks,
  digoxin therapy
• ST-segment ??? ??? ??? ? ? ??

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Central Venous Catheterization

• Indications
• - CVP monitoring
• - fluid administration to treat hypovolemia
  and shock
• - drug infusion
• - TPN
• - aspiration of air emboli
• - transcutaneous pacing leads? ??
• - poor peripheral veins ???? venous access
• Contraindications
• - renal cell tumor extension into the right
  atrium
• - fungating tricuspid valve vegetations
• - anticoagulants? ???? ??

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Central Venous Catheterization

• Techniques Complications
• - catheter tip? superior vena cava? right
  atrium ? junction? ??
• - intrathoracic pressure? ??
• CVP? ventilation??? ?? ???
• - spontaneous ??? CVP ??, ???
  CVP ??
• - controlled ??? CVP ??,
  ??? CVP ??
• - end expiration? ??????
• - catheterization site
• subclavian vein
• - pneumothorax
• - infection
• Left internal jugular vein
• - vascular erosion
• - pleural effusion
• - chylothorax
• Right internal jugular vein
• - ?? ???? ??? ???

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Central Venous Catheterization

• Seldingers technique
• - patient in the Trendelenburg position
• - full aseptic preparation
• - infiltration of local anesthetic
• the apex of the triangle(SCM m.? ????
  clavicle)
• - internal jugular vein? ???(with 25G
  needle)
• - 18G thin wall needle? ??
• - J-wire ??
• - needle ?? ? Silastic catheter? wire????
• - guide wire ??
• - intravenous catheter tubing? ??
• - sterile dressing
• - confirm with a chest radiograph

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Central Venous Catheterization

• Complications
• - infection
• - air or thrombus embolism
• - arrhythmias
• - hematoma
• - pneumothorax
• - hemothorax
• - hydrothorax
• - chylothorax
• - cardiac perforation
• - cardiac tamponade

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Central Venous Catheterization

• Clinical Considerations
• - CVP ? right ventricular end-diastolic
  volume? ??? ????? right atrial pressure? ?? ??
• - CVP? Left ventricular filling? ??? ? ??
• (? Right and Left ventricular
  performance? ??)
• - central venous waveform ? ECG ? ??
• a waves atrial contraction
• c waves tricuspid valve elevation
• (during early
  ventricular contraction)
• v waves tricuspid valve? ?????
• venous return
• x descents ??? ??? tricuspid?
• downward
  displacement
• y descents ??? ??? tricuspid? ??

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Pulmonary Artery Catheterization

• Indications
• - ??? ??,??,???? ????? ??? ??
• - ??? ??? ? ??? ?? ??
• cardiac index
• preload
• volume status
• mixed venous blood oxygenation??
• - ?????? ???? ??
• (eg. Recent myocardial infarction)
• - ???? ??? ???? ?? ??
• (eg. Thoraci aortic aneurysm repair)

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Pulmonary Artery Catheterization

• Contraindications
• - complete left bundle branch block
  (?complete heart block)
• - WPW syndrome
• - Ebsteins malformation (?tachyarrhythmias)
• Complications
• - thrombus formation
• - infection

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Pulmonary Artery Catheterization

• Techniques Complications
• - Swan-Ganz catheter
• 110 cm long
• 7.5 FR
• polyvinylchloride body
• five lumens
• - thermistor
• (thermodilution cardiac
  output computer? ??)
• - air channel
• (for inflation of the
  balloon)
• - proximal port
• (for infusions,cardiac output
  injections,right atrial pr.??)
• - ventricular port
• (for infusion of drugs)
• - distal port
• (for mixed venous blood
  sampling, pulmonary a. pr. ??)

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Pulmonary Artery Catheterization

• Techniques
• - Seldingers technique? ?? central venous
  access
• - internal jugular vein?? ???? ?15cm ?????
  distal tip? right atrium ? ??
• - respiration? ?? central venous tracing?
  ??? ?? ? ballooning
• ballooning? catheter tip? ??
  endocardium? ??? ??
• right ventricle? cardiac output?
  catheter? ??? ??
• - arrhythmias? ????? ECG? monitoring???
  cathetr? ????
• - ????? ????? ??
• catheter tip? right ventricle?? ??
• - ????? ????? ??
• catheter tip? pulmonary artery?? ??
  ( 35-45cm)
• - ?? ? ?????
• pulmonary artery occlusion pressure
• - Lateral chest radiograph? ????

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Pulmonary Artery Catheterization

• Complications
• - endocarditis
• - thrombogenesis
• - pulmonary infarction
• - pulmonary artery rupture
• - hemorrhage
• - arrhythmias
• - pulmonary valvular damage
• - pulmonary artery rupture? mortality
  50-70
• - catheterization? ??? ??? ??
  complication? risk? ??
• 72???? ??

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Pulmonary Artery Catheterization

• Clinical Considerations
• - CVP? physical examination?? ? ??? left
  ventricular preload ??
• - mixed venous blood sampling
• - air embolism ? myocardial ischemia?
  detection
• - thermistors? ?? cardiac output ??
• ??? hemodynamic values ??

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Cardiac Output

• Indications
• - pulmonary artery catheterization? ?? ?? ??
• PACs??? ?? ??? ????? ???? ???? cardiac
  output? ??? ?
• Contraindications
• - no contraindications

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Cardiac Output

• Techniques
• a. Thermodilution
• - body temperature?? ?? fluid? right
  atrium? injection
• - blood temperature? ??? ?? (Caridac
  output? ???)
• blood flow? ???? ??? ??? ??
• - thermodilution curve? ??? cardiac output
  ??
• b. Dye Dilution
• - central venous catheter? ?? indocyanine
  green dye? injection
• - arterial sampling?? systemic
  circulation?? ??? ??
• - dye indicator curve? ??? cardiac output
  ??

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Cardiac Output

• Techniques
• c. Ultrasonography
• Transesophageal echocardiography(TEE)
• - left ventricular filling (end
  diastolic volume and end-systolic volume)
• - ejection fraction
• - wall motion abnormalities
• - contractility
• - intraoperative myocardial
  ischemia? indicator?? ?? ??
• - ?? ??? ????? ?? ??
• Pulsed Doppler
• - blood flow? ??? ??
• - TEE(cross sectional area)? ????
  stroke volume? cardiac output? ??
• Transesophageal Doppler color-flow
  mapping
• - blood flow? color(flow? ??) ?
  intensity (flow? ??)? ???
• Continuous-wave suprasternal Doppler

34
Cardiac Output

• Techniques
• d. Fick Principle
• - Oxygen consumption arterial and
  venous oxygen content? ?? x cardiac output
• - CO Oxygen consumption / a-v O2
  content difference
• Clinical Considerations
• - cardiac output??? ?????? ??? ???? ?? index?
  ??

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Precordial Esophageal Stethoscopes

• Indications
• - capnography? pulse oximetry? ??
• Contraindications
• - patients with esophageal varices or
  strictures
• Technique Complications
• - mucosal irritation and bleeding
• Clinical Considerations
• - ventilation, breath sounds? quality, heart
  rate? regularity, heart tone? quality? ??

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Pulse Oximetry

• Indications
• - moderate sedation? ??? ?? ???? ??
• Contraindications
• - no contraindications
• Techniques Complications
• - pulse oxymetry? sensor? light sources?
  light detector? ??
• - oxygenated hemoglobin? deoxyhemoglobin?
  red light? ???? ???? ??? ??
• oxyhemglobin? 960nm ???? ? ? ??,
  deoxyhemoglobin? 660nm red light? ? ? ??
• - complications? ?? ??
• - calibration? ?? ??

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Pulse Oximetry

• Clinical Considerations
• - tissue perfusion? ??? heart rate? ??
• - SpO2 gt 90, but PaO2 lt 65mmHg
• oxygen-hemoglobin dissociation curve?
  left shift
• - bronchial intubation? detection? ???
• - CO poisoning?? ???? ?? ??
• COHb ? HbO2 ? ??? ??? 660nm ??? ?? ??
• - methemoglobinemia
• methemoglobin - ???? red light? ????
  ??
• SaO2 gt 85 ??? SpO2? ???? ?? ??, SaO2
  lt 85 ??? SpO2? ???? ?? ??
• - SpO2? ?? ?? ???
• - Noninvasive brain oximetry
• sensor? forehead? ?? average oxygen
  saturation? ??
• approximately 70

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Capnography

• Indications
• - ?? ??, ?? ?? ??
• ETCO2 ? ??? ??? air embolism? ???
  ??(sitting craniotomies? major complications)
• - no contraindication
• Techniques
• a. Nondiverting (Flowthrough)
• - breathing circuit? adaptor? ?? ???? CO2
  ? ???? ???? ??
• b. Diverting (Aspiration)
• - breathing circuit???? ??? gas? ??? ????
  ??

39
Capnography

• Clinical Considerations
• - esophageal intubation? ??? ??
• - bronchial intubation? ??? ???
• - ??? ???? CO2 ? ??? circuit?
  disconnection? ??
• - PaCO2 ? ETCO2 2-5mmHg? ??
• alveolar dead sapce? ??
• - lung perfusion ?? (eg. air embolism,
  cardiac output? ??, blood pressure? ??)
• ? ETCO2 ??

40
Capnography

• Clinical Considerations
• Normal capnograph
  Patient with severe chronic
  Spontaneous respiratory effort
• 
  obstructive pulmonary disease
• Incompetent expiratory
  valve
  Incompetent inspiratory valve
• or exhausted CO2

41
Anesthetic Gas Analysis

• Indications
• - ?? ?? ???? ???? ??
• - no contraindications
• Techniques
• - mass spectrometry
• - Raman spectrometry
• - ??? spectrometry
• - piezoelectric crystal oscillation
• ?? ???? ????? ??? ???? ???? ???? ??? ??

42
Electroencephalography

• Indications Contraindications
• - cerebrovascular surgery?? cerebral
  oxygenation? ???? ??? ??? ??
• - no contraindications
• Techniques
• - cerebral cortex ?? ???? electrical
  potential? ??
• - electrode??? internationl 10-20 system?
  ?? ??
• - BIS(Bispectral Index)
• ??? ?? ??? ??? ??? ?
• 65-85 ? sedation, 40-65 ? general
  anesthesia

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Evoked Potentials

• Indications
• - neurological injury? ???? ?? ??
• spine and spinal cord tumor resection,
  brachial plexus repair, cerebral tumor resection,
• thoracoabdominal aortic aneurysm
  repair
• - no specific contraindications
• Techniques Complications
• - ?? ? sensory or motor pathway?
  electrophysiological response? ??
• Clinical Considerations
• - persistent oblieration of EPs
  postoperative neurological deficit ? ??

44
Temperature

• Indications
• - ?? ?? ??
• - 15? ??? ??? procedure??? ????
• Techniques Complications
• - thermistors ? thermocouple? ??
• - probe? ?? trauma (eg. Rectal or tympanic
  membrane perforation)

45
Temperature

• Clinical Considerations
• - Hypothermia Body temperature lt 36?
• ?? ???? ?? ??
• ? cerebral or
  cardiac ischemia ? ??
• - postoperative shivering
• ? arterial ?? ??? 5??? ??
• ? myocardial ischemia, angina? ??? ??
• ? normothermia? ??? ??

46
Temperature

• Clinical Consideratinos
• - Core temperature (Central blood
  temperature)
• phase I ?? ??? ? 1?? ??? 1-2 ? ? ??
• vasodilation? ?? ?? ?????
• (abdome, thorax ? arms,
  leg)
• ?? warming blankets??
  30? ?? prewarming
• phase II 3-4?? ??? ??? ??? ??
• ???? ?? ??
• forced air warmming
  blanket
• heated humidification of
  inspired gas
• warming intravenous fluid
• phase III ? ??? metabolic ? ??? ???
  ????
• - monitoring site
• tympanic membrane brain temperature ??
• rectal temperature core temperature?
  ???? ??, ??? slow reponse
• nasopharyngeal temperature ??? core
  temperature ??, epistaxis ???
• axillary temperature skin perfusion?
  ?? ???? ? ??

47
Urinary Output

• Indications
• - congestive heart failure, renal failure,
  advanced hepatic disease ??
• - cardiac surgery
• - aortic or renal vascular surgery
• - craniotomy
• - major abdominal surgery
• Contraindications
• - infection? ???? ?? ???? ??
• Technique Complications
• - infection? risk? ????? chamber? bladder??
  ??? ??
• Clinical Considerations
• - thermistor? foley catheter tip? ?? bladder
  temperature ????
• urinary output? ??? core temperature?
  ???? ??
• - kidney perfusion and function? ??
• - renal, cardiovascular and fluid volume ???
  indicator
• - oliguria urinary output lt 0.5mL/kg/h

48
Peripheral nerve stimulation

• Indications
• - Neuromuscular blocking agents? ???? ?? ??
• agents? ?? sensitivity? ??? ???
• - no contraindications
• Techniques Complications
• - peripheral motor n.? ??? ? response? ??
• - most common site
• ulnar n. stimulation of the adductor
  pollicis m.
• facial n. stimulation of the
  orbicularis oculi
• Clinical Considerations
• - adductor pollicis? ????? airway?
• ???? muscle? ??? ???? ??
• musle group? sensitivity? ??
• - other indicators
• head lift? 5??? ??
• ??? 25cmH2O ? inspiratory pressure ??
• forceful hand grip ??