Transthoracic echocardiography (TTE) Is @ noninvasive form of echocardiography. ‘otner options : Transesophageal echocardiography (TEE) Is a minimally Invasive procedure and could be associated with serous complications like esophageal rupture and mediastinitis in the presence of esophageal Injury or disease. In the absence of esophageal disease, the risk is low. Ragial artery cannulation ana pulmonary artery catheterization are invasive Radial artery is the preferred artery for invasive blood pressure monitoring because of ease of cannulation, Presence of collateral bloos flow and less associated complications, But, before cannulating the radial artery, it is essential to perform a modified Allen's test in order to determine the adequacy of collateral flow to the hand. ‘The other arteries which can be use¢ for invasive blood pressure monitoring are ulnar, brachial. axillary. land femoral arteries and less commonly dorsalis pedis, posterior tibial, and superficial temporal arteries. A simple mnemonte to remember these In descending order of their numbering |= nature. The mantle Zone of the warth Is orange, the land lo giey. the arass is green, the buttoMly on the grass lo pink. the Sky fe blue, anc the sun t= yellow, Pear #2171: Color Coding of Intravenous Cannulae Trauma Patients, Major Surgery. Intra Partumy/Post Partum, GI ieeas, 18S Grey 2SEmUMIN | Ghipie blood Hansfers, High volume of Flute 473 whine 1Z0mvmin Newly agaea, 18G Green min stusy ” “ 22G Blue a2 mYmiN__ Small or Fragile veins, Cytotoxic Therapy 24G Yellow = 20mimin For pediatric Usage 260 Violet tamumin Newly added Uinar nerve stimulation at wrist Is the best nenwe to assess the adequacy of anestnesia Neuromuscular blockade Is measured using a peripheral nerve stimulator. Ulnar nerve ‘Contraction of adauctor pollicis Facial newe Contraction of orpicularis ocult Left attial pressure (LAP) is indirectly measured through pulmonary capillary wedge pressure (PCWP). LAP nas been the gold standard for evaluating mitral stenosis and decompensated congestive neat ralture. Swan-Ganz catheter is used for pulmonary artery catherization Cardiac arrhythmias is the most frequent complication. ‘Calneter Is incorporated with thermistors that can be used to measure cardiac output trom which a muttitude of emoaynamic values can be derved.Measurement of pressures in right atrium. right ventricie and pulmonary artery Cardiac output Oxygen saturation. pulmonary samples to tule out left-right shunt Monitoring ten venicle tiling pressure 2 Dinterentiate cariogenie from nan cardiogenic pulmonary edema “The mest common complication oF pulmonary artery catheterization Is arrhythm! Je the occurrence of these arythmias Is so commen, it Is considered as an indicator of placement of + Armytnmias, ventricutar npnitation, 2 Rignt Bunale branch block. complete neart Block Pulmonary artery rupture Pulmonary artery pseudoaneurysm + Uisinterpretation of dats Sezens ventiation in the penoperative period, Careline output measurements technique Esophageal Despier Tromecte bloimpedance 2 echocaraiograpny ‘Transesophageal echocardiography Is tne most sensitive indicator of myocardial ischemia in the perioperative setting. New regional wall motion abnormalities and decreased systolic wall thiekening on transesophageal ‘echocaraiography are more sensitive than ECG. Ischemia may be indicated clinically by a suciden onset intraoperative arrhythmia or conduction block:Right intemal jugular vein Is the most preferred for central venous cannulation Reasons for this preference are = Consistent anatomic location of the internal jugular vel 2 Easily identinapie surtace landmarks, = Subclavian vein: greater risk of pneumothorax. 2 Cen internal jugular vein: greater nei at pleural effusion & enylotnarax + Femoral vein: Increased risk of thromboomballe complications, infection and vascutar injury. “Trippie-lumen central venous catheterization of night UV. Entry Inte the pulmonary artery I= indicated by an tnerease in diastone pressure. Normal cardiovascular pressure (in mm Hg) Ares Pressure (in mm Ha) Peak systolic: 15-30 Characteristic intracardiac pressure wave forms during passage through the heart CRA Lav] (Pew)LEAD It Sost for detecting arrhythmias anc inferior wall MI. For arrhythmia, esophageal leads are better than lead 1! but they are not yet put inte wide use. on transesophageal echocardiography aro more sensitive than EG. leftieg. The limb leacs (ILI) form the points OF what Is KNOWN as Elthoven’s tangle Capnography cannot be used to monttor the depth of anesthesia, Capnoaraphy is a quantitative measure of end-tidal carbon dioxide which is used to assess ventilation in the perioperative period and confirm correct placement of an endotracheal tube. Monitors used to assess the depth of anesthesia Etectroencephatography (EEG) Bispectral index (BIS) Entropy Evoked responses (EP) - Motor EP, sensory EP (Aualitory, visual, brain stem evoked potential) porone Isoelectric GEG Is not seen curing Mypertnermi=a = Brief periods during normal maintenance of anesthesia 2 Prorouna nypotnermia = GB oscillations © arousable state of seaation . 8 osculations wih 5 daminance: surgically anestnenzea state Distal esophagus Is the best site for core temperature montoning during matignant hyperthermia. Note: Pulmonary artery—Most accurate but not used routinely due fo a higher incidence of complications, Rie uscfulin patients already on Swan Ganz catheter (Oral (sublingual): Can be infuenced by mouth breathing, tachypnea, and ambient temperature Anilla: Readings are influenced by contact with probe, skin perfusion, enviranment, ete Rectum: Higher than central sites due to heat-producing flora in feces. tympanic membrane, Nasopnarynx, ‘The tympanic membrane measures ne brain temperature most accurately because the tympanic membrane and the hypothalamus share a common blood supply. So, measuring the temperature at this site reftects thermal information at the primary site of thermoregulation. Disadvantages are trauma during insertion and cerumen insulation, so it is not routinely used. Sweating is best proserved auring anesthe: ‘omer options + General anesthetics decrease ine thresholds (triggering core temperatures) for vasoconstriction and shivering by 2°C to °C = Nonsnivering thermogenesis does not occur in anesthetized pationts, Radial artery cannulation is an invasive method of blood pressure mentoring. ‘oximeter measures oxygen seturation of blood and measure neart rate. ‘Out of options b and ¢, the best would be option ¢ as racial artery cannulation Is solely for cardiovascular Respiratory monitoring invelves the use of capnegrapny 2 Anestnetic gas analysis (oxygen analysis, piezo electric analysis) 2 Spirometry 1 impedance pneumography is 2 metnod of monitonng of apnea,Carbon monoxide polsoning |s associated with a falsely high Os saturation, loxynemogionin (}1502) apsorns more infrareet light (940 nm) Deoxynemogiobin absorbs more red light (S60 nm) Camoxyhemoglobin (COHb) and HbO, absorption spectrum i= similar ‘Thus in patients wih carbon monoxide poisoning, a falzely high SPOz of 95% iz seen irrespective of the actual SpOz value Severe anemia, low cardiac output states. hypevolem! associated wiih falsely low oxygen salurailon values, and increased systemic vascular resistance are, (note: with nermat Sa@2, anemia has ite effect on SpOs. However. In the presence of hyPoxla, SPO2 readings underestimate SaOz In anemic patents) (CO-oximeter is tne best monitor to detect abnormal hemoglobins. (CO-oximeter uulzes an eight wavelength sensor (unlike pulse oximeter which uses twe wavelengths) to distinguish between oxygenated bood, deoxygenated blood and bloog containing CO. (CO-oximeter ie usetul in measuring: = Carpexynemogiopin + Metnemogienin Pulse oximetry is a non-invasive measurement of ihe oxygen saturation of nemogianin. = Faisely nian - carboxynemogiobinemia 1 Faisoly low severe anemia, low cardiac oulput states, nypovolemie, increased systemic vascular = 80% 16 85%, irrespective of the arterial oxygen saturation - methemoglovinemia {Expired C0) ; a v BD 51.04% answered this question correctly xpired COp> a Time> The above capnographic waveform snows, vated inspiratory baseline, which depicts rebreathing. Rebreathing of COz may occur due to exhausted coda lime or Incompetent expiratory valve in closed- circuit breathing systems. Malignant hyperthermia: Progressive rise in ETCO: Bronchospasm: Shark nn appearanceC0» (mmHg) oon o NNO Real-Time | ‘The image given in the question snows a capnograph with some carbon dioxide detected initially followed by aosence of carbon dioxide. this is typical of esophageal intubation. Matignant nypertnermia — progressive rise in Coz Rebreathing of CO2 - elevated inspiratory pasetine. “Tracheal intubation - normal eapnagraph, ‘The Image in the given question snows a capnograpn with a suiden and progressive increase in ETCOs which is typical of malignant hyperinermia, Rebreathing of CO2 would result in fa ‘Tracheal intubation would shaw a normal capnegraph Jot and most censitive Indicators of malignant hyperthermia, Ire of the inspired CO2 to return to zero in the capnograph Esophageal intubation would initialy detect some CO: because of swallowed alr in the stomach which later returns to zero. EtCO.mmHg Time ‘The Image shown is that of normal capnegraphy seen during controlled mechanical ventilation Malignant hyperthermia — progressive rise in CO2, Rebreathing of CO; - elevated inspiratory baseline Esophageal intubation - initially would detect some CO2z which later returns to zero, Ideal for apnea monitering in an intubated patient is capnography. Impedence pulmonometry is most commonly used for apnea monitoring in @ nen-intubated patient and is also used in home monitoring of neonatal apnea. Pulse oximetry and CO-oximetry is used to assess oxygenation.7° so 50 ao 30 40 ° ETCOemm Hg Time ‘The Image in the given question snows a capnograph with clefts curing phase Il! wnich indicates spontaneous breathing efforts by tne patient during controlled mechanical ventilation. Also known as curare notch or cleft. Rebreathing - elevated inspiratory baseline Pulmonary embolism - sueden fallin ena taal Oz Malignant hyperthermia — persistent rise in COz