2.

5
12 September 2013
Danilo Mata, MD Physiologic Monitoring
Things done well and with a care, exempt themselves from fear. of Surgical Patients
-William Shakespeare

o Patients who need continued cardiopulmonary support

[TransGroup’s note: Orange texts are those from Dr. Mata’s or continued invasive monitoring to avoid major
ppt. Tables and figures with orange borders and contain black morbidity and death should be transferred to an
texts are also from his ppt. Others are from Schwartz and intensive care unit.
Way] o Intermediate care is usually provided on an inpatient
nursing unit until the patient's recovery can continue at
OUTLINE PAGE home during the convalescent phase.
Surgical Care: Introduction 1
Pre-operative Care 1  In admitting a patient for surgery, the following questions
should be answered:
Diagnosis 1
1. Is the diagnosis firmly established?
Pre-operative Evaluation 2
2. Has the disease and the procedure been adequately
Techniques 2 explained?
Risk Assessment 2 3. Is there a need for further assessments to stage the
Operative Severity 3 disease or to deal with other diseases?
Factors Affecting Operative Risk 3 4. How risky is the operation?
Pre-operative Preparation 3 5. Are corrections of blood volume, nutritional status or
Surgical Care* 3 electrolyte imbalances needed?
Post-operative Care 4 6. What are the prophylaxis measures needed?
Hemodynamic Monitoring 5 7. What are the particular preparations required prior or
during the surgery?
Respiratory Monitoring 11
Renal Monitoring 11
PREOPERATIVE CARE
Neurologic Monitoring 12
PREOPERATIVE ASSESSMENT

GENERAL BEHAVIORAL OBJECTIVE  Cardiovascular System (Myocardial

 Understand the importance of assessment of patient prior Infarction)
to surgery to identify risk factor for adverse event and to  Respiratory System
initiate appropriate treatment  Blood Pressure
History
 Diabetes
SURGICAL CARE: INTRODUCTION  Bleeding
 care of the patient with a major surgical problem commonly  Cerebrovascular Accident (Stroke)
involves distinct phases of management that occur in the  Drugs, Allergies and Alcohol
following sequence  Reactions to Anesthesia
 CVS
 RS
1. PRE-OPERATIVE CARE Examination
 Nutritional Status
 Diagnostic
 Mental Status
 Pre-op Evaluation
 Neck, Jaw and Presence of Dentures
 Pre-op Preparation
 Routine
2. PERI-OPERATIVE Investigators
 Special
 Anesthesia
 Operation
THE DIAGNOSIS
3. POST-OPERATIVE CARE
This can be established by a combination:
 Post Anesthetic Observation
 Intensive Care
 Intermediate Care  Chronology of OPD notes
 Convalescent Care The  Chronology of correspondence or
patient’s consultations
document  Report of laboratories, radiological and
 Preoperative care: histopathological investigations
o diagnostic workup is concerned primarily with
 Complete history and PE
determining the cause and extent of the present illness The Patient
 Note any changes in S/Sx
o Preoperative evaluation consists of an overall
The  Complete any missing links
assessment of the patient's general health in order to
Family/  Ask for any voluntary information
identify significant abnormalities that might increase
Relatives
operative risk or adversely influence recovery
o Preoperative preparation includes interventions
dictated by the findings on diagnostic workup and OBJECTIVES
preoperative evaluation, and by the nature of the  Diagnosis
expected operation  Cause
 Postoperative Care  Extent of Disease (Staging)
o postanesthetic observation phase of management is  Operability
the few hours immediately after operation during which  Informed Consent
the acute reaction to operation and the residual effects
of anesthesia subside

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

PRE-OPERATIVE EVALUATION RISK ASSESSMENT

 Comprehensive
 Goals: Age
1. To assess patient’s overall state of health Cardiovascular
2. To decrease risk of surgical treatment Respiratory Diseases
3. To guide pre-operative preparation Risk Smoking
Factors GI: Malnutrition, Jaundice and Adhesions
PRE-OPERATIVE EVALUATION TECHNIQUES I Renal Dysfunction
 Patient’s General Health Obesity
o Hemodynamic function Diabetes
o Respiratory rate Surgeon and Operative Severity
o CNS function Age
 Significant Abnormality  Distinction must be made between physiologic
 Operative Risk state and chronological age
 American Society of Anesthesiologists Physical Status:  Age less mobile, intercurrent disease, less
physiological reserve
Class Physical Status  Condition with regards to IVF and narcotic
1 Normal healthy patient analgesia
2 Patient w/ mild systemic disease  More likely to have wound infections
3 Patient w/ severe systemic disease  In 65 y/o, CVA 1%
Risk
Patient w/ severe systemic disease that is a  In 80 y/o, CVA 3%
4 Factors
constant threat to life Obesity
II
Moribund patient who is not expected to  BMI>30
5  Increased risk in:
survive w/o operation
Declared brain-dead patient whose organs are  Deep Vein Thrombosis (DVT)
6  Wound infection and Dehiscence (wound
being removed for donor purposes
rupture along surgical suture)
 Respiratory complications & sleep apnea
DIAGNOSTIC & PRE-OP EVALUATION: TECHNIQUES
 Intercurrent diseases
 Operative difficulty
 Present Illness  Relative risk of mortality: 3-5
 Past History Predictors
 Concurrent Disease: Major
Endocrine Diabetes  Unstable coronary syndrome
Hypertension, Myocardial  Decompensated Cardiac Heart Failure (CHF)
Cardiovascular
Infarction (MI)  Significant arrhythmia
HISTORY
Respiratory COPD  Severe valvular disease
Coagulopathy Hemophilia Intermediate
Kidneys Renal Failure  Mild angina
Liver Cirrhosis  Compensated Congestive Cardiac Failure
 Drugs (CCF)
 Radiotherapy  DM
 Head to toe  History of MI
 Local examination Minor
Risk
 Hemodynamics:CV  Age
Factors
 Respiration  Abnormal ECG, etc.
P. E. III:
 Neuro Exam Cardio-
 Radiotherapy: Pelvic Exam Actions
vascular
 Pap Smear Evaluation
Diseases
 Sigmoidoscopy  Clinical, specialist opinion, ECG, chest x-ray,
 Blood Count echocardiogram, others
 Blood Chemistry: Renal and Liver Function If Major:
Tests  Cancel unless life-threatening
LAB TEST
 Urinalysis: T3, T4, Free T4 index  Consider coronary artery bypass grafting
 X-ray (CABG) prior to elective surgery
 ECG If Intermediate:
 Hemostatic Function Test  Objective performance
 Lung Function Test: FVC, FEV1 Hypertension
 X-ray: angiography, CT scan, radionuclear  Indicates coronary artery disease (CAD)
SPECIAL  More likely to develop hypotension during
 Ultrasound
TEST surgery
 Echocardiography
 MRI  Control prior to surgery
 Blood Gas Analysis Estimate Functions:
Risk
CONSULT  Anethesiologist  Clinical and specialist opinion
Factors
 Cardiologist  ABG
IV:
 CXR
Respi-
 Spirometry: FEV1/FVC, PEFR (Peak Expiratory
ratory
Flow Rate)
Diseases

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

Chest Infections: o Infection

 Postpone for 2 weeks o Hypoxia
 Antibiotics and prophylaxis o Hypothermia
Chronic Obstructive Airways Disease  Jaundice and anemia
(COAD)  Splenic infarctions: sepsis
 Consult with specialist  Prevention: warm, well hydrated, well
 Reschedule surgery analogleed
Plan to transfer to ICU for mechanical  Consider exchange transfusion in saline salt
ventilation; Correct coagulopathies
 Pending: lung function, type and duration of
surgery OPERATIVE SEVERITY
Smoking
Procedures under LA (laparoscopy ata to)
 10 cigarettes=6 fold increase post-op Minor
Uncomplicated hernia
respiratory complications
 CO has higher affinity in haemoglobin than O2 Appendectomy
 Nicotine increases HR and BP Moderate Cholecystectomy
 Hypersecretion of thick mucus Transurethral Resection of Prostate (TURP)
 Stop for 3 months prior to operation to Laparotomy
Major
improve pulmonary functions Bowel resection
 Stop 1 to 2 days to decrease CO levels Abdominoperineal (AP) resection
Gastro-Intestinal Diseases Major + Hepatico-pancreatic surgery
Malnutrition Emergency surgery
 Loss of 15-30% body weight is associated
with severe impairment of physiological SPECIFIC FACTORS AFFECTING OPERATIVE RISK
function
A. COMPROMISED/ALTERED HOST
 No evidence of benefit of preop feeding
Adhesion 1. Nutritional Assessment
 Higher risk for bowel injury and subsequent Increase death rate
fistula formation Weight Loss >20%
Increase infection rate
 Longer duration of surgery Albumin ≥ 3g%
Jaundice Lab Test
Transferrin ≥ 150 mg%
 Poses a risk for: Supportive Therapy Weight Loss > 10% B.W.
o Sepsis
o Clotting d/o 2. Assessment of Immune Competence
o Renal failure  Immune deficiency directly proportional to malnutrition
o Liver failure  Tests:
o Fluid and electrolyte abnormalities o Lymphocyte count ≥ 1000/mm3
o Drug metabolism o Cell-mediated immunity via skin test
Management: 3. Factors leading to increase infection
 Vitamin K a. Drugs
 Fresh Frozen Plasma (FFP)  Corticosteroid  Cytotoxic
 Hydration and diuretics and lactuloase  Prolonged antibiotic use  Immunosuppressive
 Antibiotics  Radiotherapy + steroid agents
Risk  Nutrition b. Renal Failure
Factors Renal Disorders c. Immunologic deficiency
V  Identify the causes:  Lymphoma  Granulocytopenia
Cardiac  Leukemia  Decreased γ-globulin
Pre-renal
Hypovolemia d. Diabetes mellitus
Acute tubular necrosis B. PULMONARY DYSFUNCTION
Renal
(drug inducers)  Importance
Post-renal Obstructive uropathy a. Major intrathoracic operation
 Identify patients for renal dialysis b. Major abdominal operation
 Check potassium levels c. Major intracranial operation
 Accurate fluid balance
o Look for signs of fluid overload C. DELAYED WOUND HEALING
o Do not misinterpret polyuremic phase  Decreased protein  Dehydration
Hematologic Disorders  Vit. C deficiency  Edema
Anemia  Severe anemia  Infection
 Correction 1 week pre-op  Drugs  Radiation
 Obesity
 Correction day preop is undesirable
 Hemodilution D. DRUG EFFECTS
Thrombocytopenia Hypersensitivity
 In splenomegaly, platelets must be transfused
immediately preop and on ligating the arterial PRE-OPERATIVE PREPARATION
supply  Before operation, consider:
Sickle Cell Disease o Wound
 Crisis caused by: o Physical stress
o Dehydration o Physical trauma

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

 Hence, surgeons must practice GOOD PREAPARATION: primary responsibility for cardiopulmonary
function
Drugs  surgeon is responsible for the operative
 Bronchodilator site and all other aspects of the care not
 Anti-thyroid drug directly related to the effects of anesthesia
Pre-operative  Patients who require continuing ventilatory
Exercise
Treatment or circulatory support or who have other
 Chest physiotherapy
 Postural damage conditions that require frequent monitoring
 Stop smoking are transferred to ICU
 Nature and purpose of preop study  starts with complete recovery from
Inform the anesthesia and lasts for the rest of the
 Risks and consequences of surgical
Patient hospital stay
procedures Intermediate
 patient or the patient's legal guardian  patient recovers most basic functions and
Operative becomes self-sufficient and able to
must sign (in advance) a permit
Permit continue convalescence at home
authorizing a major or minor operation
Skin penetration  transition period from the time of hospital
Convalescent
 Do the evening before operation discharge to full recovery
 Wash with soap and water  During the first two phases, care is principally directed at
 Shower maintenance of homeostasis, treatment of pain, and
 Shaving done immediately before prevention and early detection of complications.
operation
Diet INTERMEDIATE CARE
 Omit :
PULMONARY CARE
Solid food 12 hrs prior to op
 Decreased lung function:
Fluids 8 hrs prior to op o Decreased vital capacity
Enema o Decreased functional residual capacity
 Not routinely done o Lung edema
 Indications:  Acute Respiratory Failure
- Colon/rectal/anal operation RR > 22 (tachypnic)
- Abdominal operation Tidal Volume < 4 mL/kg (low)
Bedtime & pre-anaesthetic medication
PCO2 > 45 mmHg (acutely elevated)
Pre-operative Special Orders
PO2 < 60 mmHg (low)
Orders  Blood transfusion: type & cross-match
 Atelactasis
 Nasogastric tube
 Treatment includes:
- Emergency operation
o immediate endotracheal intubation
- patients w/ obstruction
o ventilatory support to ensure adequate alveolar
 Bladder catheter
ventilation
- Hourly monitoring of urine
- Urinary retention FLUID AND ELECTROLYTE
- Abdomino-pelvic procedures  fluid replacement should be based on the following
 Venous access & hemodynamic considerations
monitoring (1) maintenance requirements
- Marked blood loss (2) extra needs resulting from systemic factors (eg, fever,
- CVP monitoring burns)
 Pre-operative hydration (3) losses from drains
 Continuing medications (4) requirements resulting from tissue edema and ileus
- Insulin (third space losses)
- Cardiac drugs  Daily maintenance requirements for sensible and insensible
- Antibiotics loss in the adult are about 1500–2500 mL depending on
 Prophylactic antibiotics the patient's age, gender, weight, and body surface area.
o rough estimate=multiply patient's weight in kilograms
SURGICAL CARE* by 30 (eg, 1800 mL/24 h in a 60-kg patient)
Very confusing ‘tong part ng ppt ni doc kasi lahat naman ng  Maintenance requirements are increased by fever,
procedures na ito ay SURGICAL CARE. Pero entries under this heading hyperventilation, and conditions that increase the catabolic
are very much similar sa Intro to Postoperative part ni Way. So we rate.
followed the Way way. :P
 Based on surgical procedure PAIN
o Surgical wound care  common sequela of intrathoracic, intra-abdominal, and
o Drainage care major bone or joint procedures.
o Position of extremity  limitation in motion due to pain sets the stage for venous
o Orthopedic traction stasis, thrombosis, and embolism
o Continuous suction  Gentle handling of tissues, expedient operations, and good
muscle relaxation help lessen the severity of postoperative
POST-OPERATIVE CARE pain
Divided into three phases:
 All patients should be monitored in PACU POST-OPERATIVE COMPLICATIONS
Immediate or
(Post-anesthesia Care Unit) initially  Types accdg. to timing:
post-
following major procedures o Immediate
anaesthetic
 anesthesiology service generally exercises

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

o Early
o Delayed
 Cardio-repiratory- status
o Hypotension
o Bradycardia - tachycardia
o Hypo - hyperthermia
o Hypoglycemia
o Respiratory arrest (Atelectasis-most common
pulmonary complication; common among elderly or
overweight)
o Cardiac arrest (Fluid overload in patients with limited
myocardial reserve is the most common cause)
 Coagulopathy
o Patients with hereditary coagulation disorders can
safely undergo surgical procedures, provided that a
diagnosis of the defect is made prior to surgery
o Coagulation factor replacement in the perioperative
period reduces the risk of bleeding complications in
these patients
 Surgical procedures
o Thyroid crisis (Both hyper- and hypothyroidism
represent serious problems for patients undergoing
surgery. It may be difficult to establish an adequate
airway in patients with large goiters. The hyperthyroid
patient undergoing surgery is apt to develop
hypertension, severe cardiac dysrhythmias, congestive
heart failure, and hyperthermia)
o Bowel/entero cutaneous – fistula
o Pneumothorax – tension (follow insertion of a *don’t forget the informed consent before performing
subclavian catheter or positive-pressure ventilation, operations
but it sometimes appears after an operation during
which the pleura has been injured (eg, nephrectomy or HEMODYNAMIC MONITORING
adrenalectomy)  Definition: Using invasive technology to provide
o Bleeding – hematoma quantitative information about vascular capacity, blood
o Wound dehiscence/infection volume; pump
o Burst abdomen  Additional information may be obtained if various
o Cardiac tamponade modifications of the standard pulmonary artery
o Compartment syndrome catheterization (PAC) are used.
o Urinoma  By combining data obtained through use of PAC with
results obtained by other means (i.e., blood Hgb
ALGORITHM FOR ELECTIVE SURGERY concentration and oxyhemoglobin saturation), derived
estimates of systemic O2 transport and utilization can be
calculated.

Directly Measured and Derived Hemodynamically Data

Obtained via Bedside PAC
PAC w/
Derived
Standard PAC additional
Parameters
features
CVP Sv O2 SV (or SVI)
(continuous)
PAP QT or QT* SVR (or SVRI)
(continuous)
PAOP RVEF PVR (or PVRI)
Sv O2 (intermittent) RVEDV
QT or Q T* DO2
(intermittent) VO2
ALGORITHM FOR EMERGENCY SURGERY IN ELEDERLY ER
QS/QT

PURPOSE OF INVASIVE HEMODYNAMIC MONITORING

 Early detection, identification, and treatment of life-
threatening conditions such as heart failure and cardiac
tamponade

COMMONLY USED TERMINOLOGIES

1. PRELOAD

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS
 is the degree of muscular fiber stretching present in the
ventricles right before systole
 is the amount of blood in a ventricle before it contracts;
also known as “filling pressures”
Preload of: Reflected by:
PCWP (Pulmonary Capillary Wedge
Left Ventricle Pressure) or pulmonary artery occlusion
pressure (PAOP)
Right Ventricle CVP (Central Venous Pressure)
 Starling's law of the heart states that the force of muscle
contraction depends on the initial length of the cardiac
fibers
 is the stretch of ventricular myocardial tissue just before
the next contraction
 determined by end-diastolic volume (EDV)
 PAOP or PCWP is measured by transiently inflating a balloon
at the end of a pressure monitoring catheter positioned in a
small branch of the pulmonary artery, approximates left
ventricular End-Diastolic Pressure
o presence of atrioventricular valvular stenosis will alter
this relationship
 Clinicians frequently use EDP as a surrogate for EDV, but
EDP is determined not only by volume but also by the
diastolic compliance of the ventricular chamber
 Ventricular compliance is altered by various pathologic
conditions and pharmacologic agents
 relationship between EDP and true preload is not linear, but
rather is exponential
2. AFTERLOAD
 another term derived from in vitro experiments using
isolated strips of cardiac muscle
 defined as the force resisting fiber shortening once systole
begins
 factors comprising the in vivo correlate of ventricular
afterload:
o ventricular intracavitary pressure
o wall thickness
o chamber radius
o chamber geometry
3. CARDIAC OUTPUT (QT)
 is the amount of blood ejected from the ventricle in one
minute
4. CARDIAC INDEX (QT*)
 Cardiac output indexed to body surface area
5. SYSTEMIC VASCULAR RESISTANCE (SVR)
 Commonly approximates AFTERLOAD because the factors
of afterload are difficult to assess clinically
 defined as mean arterial pressure (MAP) divided by cardiac
output
6. PULMONARY VASCULAR RESISTANCE (PVR)
7. CONTRACTILITY
 defined as the inotropic state of the myocardium
 said to increase when the force of ventricular contraction
increases at constant preload and afterload
 Clinically, contractility is difficult to quantify, because
virtually all of the available measures are dependent to a
certain degree on preload and afterload
 If pressure-volume loops are constructed for each cardiac
cycle, small changes in preload and/or afterload will result
in shifts of the point defining the end of diastole
 These end-diastolic points on the pressure-versus-volume
diagram describe a straight line, known as the isovolumic
pressure line
 A steeper slope of this line indicates greater contractility
Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta
MEASUREMENT OF CARDIAC OUTPUT BY
THERMODILUTION
 Before the development of the pulmonary artery catheter
(PAC), determining cardiac output (QT) at the bedside
required:
o Careful measurements of O2 consumption (Fick
method) or
o Spectrophotometric determination of indocyanine
green dye dilution curves.
 Measurements of QT using the thermodilution technique:
o Simple and reasonably accurate
o Can be performed repetitively, and the principle is
straightforward.
o If a bolus of an indicator is rapidly and thoroughly
mixed with a moving fluid upstream from a detector,
then the concentration of the indicator at the detector
will increase sharply and then exponentially diminish
back to zero.
 Area under the resulting time-concentration curve
o Function of the volume of indicator injected and the
flow rate of the moving stream of fluid.
o Larger volumes of indicator result in greater areas
under the curve
o Faster flow rates of the mixing fluid result in smaller
areas under the curve.
 When QT is measured by thermodilution:
o Indicator = heat
o Detector = temperature-sensing thermistor at the
distal end of the PAC
 Relationship used for calculating QT is called the
Stewart-Hamilton equation:
o V = volume of the indicator injected
o TB = temperature of blood (i.e., core body
temperature)
o TI = temperature of the indicator
o K1 = constant that is the function of the specific heats
of blood and the indicator
o K2 = empirically derived constant that accounts for
several factors:
 Dead space volume of the catheter
 Heat lost from the indicator as it traverses the
catheter
 Injection rate of the indicator
o ∫TB(t)dt = area under the time-temperature curve
 Determination of cardiac output by the thermodilution
method is generally quite accurate, although it tends to
systematically overestimate QT at low values.
o Changes in blood temperature and QT during the
respiratory cycle can influence the measurement.
o Results generally should be recorded as the mean of
two or three determinations obtained at random points
in the respiratory cycle.
 Using cold injectate widens the difference between TB and
TI and thereby increases signal-to-noise ratio.
o Nevertheless, most authorities recommend using room
temperature injectate (normal saline or 5% dextrose in
water) to minimize errors resulting from warming of
the fluid as it transferred from its reservoir to a syringe
for injection.
 Technologic innovations have been introduced that permit
continuous measurement of QT by thermodilution. In this
approach:
o Thermal transients are not generated by injecting a
bolus of a cold indicator, but rather by heating the
blood with a tiny filament located on the PAC upstream
from the thermistor.
Page 6 of 13
 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS
o By correlating the amount of current supplied to the
heating element with the downstream temperature of
the blood, it is possible to estimate the average blood
flow across the filament and thereby calculate QT.
 Based upon the results of several studies,
continuous determinations of QT using this
approach agree well with data generated by
conventional measurements using bolus injections
of a cold indicator.
Mixed Venous Oximetry
Fick equation:
QT =VO2/(CaO2 – Cv O2)
o CaO2 = content of O2 in arterial blood and
o Cv O2 = content of O2 in mixed venous blood
o Can be rearranged as follows:
Cv O2 = CaO2 – VO2/QT
o If the small contribution of dissolved O2 to Cv O2 and
CaO2 is ignored, the rearranged equation can be
rewritten as:
Sv O2 = SaO2 – VO2/(QT x Hgb x 1.36),
 Sv O2 = fractional saturation of Hgb in mixed venous
blood; function of O2 (i.e., metabolic rate), QT,
SaO2, and Hgb
 SaO2 = fractional saturation of Hgb in arterial blood
 Hgb = concentration of Hgb in blood
 Subnormal values of Sv O2 can be caused by:
o  in QT (due, for example, to heart failure or
hypovolemia)
o  in SaO2 (due, for example, to intrinsic pulmonary
disease)
o  in Hgb (i.e., anemia)
o  in metabolic rate (due, for example, to seizures or
fever)
 With a conventional PAC, measurements of Sv O2 require
aspirating a sample of blood from the distal (i.e.,
pulmonary arterial) port of the catheter and injecting the
sample into a blood gas analyzer. Therefore for practical
purposes, measurements of SO2 can be performed only
intermittently.
 By adding a fifth channel to the PAC, it has become
possible to monitor Sv O2 continuously.
o Fifth channel contains two fiber-optic bundles, which
are used to transmit and receive light of the
appropriate wavelengths to permit measurements of
Hgb saturation by reflectance spectrophotometry.
o Despite the theoretical value of being able to monitor
Sv O2 continuously, data are lacking to show that
this capability favorably improves outcome.
 In a recent prospective, observational study of 3265
patients undergoing cardiac surgery with either a standard
PAC or a PAC with continuous SO2 monitoring:
o Oximetric catheter was associated with fewer arterial
blood gases and thermodilution cardiac output
determinations, but no difference in patient
outcome.
 Because PACs that permit continuous monitoring
of SO2 are much more expensive than
conventional PACs, the routine use of these
devices cannot be recommended.
 Saturation of O2 in the right atrium or superior vena cava
(ScvO2)
o Correlates closely with Sv O2 over a wide range of
conditions, although the correlation between ScvO2
and Sv O2 has recently been questioned.
 Since measurement of ScvO2 requires placement
of a central venous catheter (CVC) rather than a
Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta
PAC, it is somewhat less invasive and easier to
carry out
 By using a CVC equipped to permit fiber-optic
monitoring of ScvO2, it may be possible to titrate
the resuscitation of patients with shock using a
less invasive device than the PAC.
Right Ventricular Ejection Fraction
 Ejection fraction (EF)
o calculated as (EDV – ESV)/EDV, where ESV is end-
systolic volume
o is an ejection-phase measure of myocardial
contractility
 By equipping a PAC with a thermistor with a short time
constant, the thermodilution method can be used to
estimate RVEF.
o Measurements of RVEF by thermodilution agree
reasonably well with those obtained by other means,
although values obtained by thermodilution typically
are lower than those obtained by radionuclide
cardiography.
 Stroke volume (SV) = EDV – ESV.
 Left ventricular stroke volume (LVSV)
o also equals QT/HR, where HR is heart rate.
o Because LVSV is equal to RVSV, it is possible to
estimate right ventricular end-diastolic volume by
measuring RVEF, QT, and HR.
COMPUTATION CONSTANT
 Computation constant is based on the:
o Type of catheter
o Temperature (iced or room temp) of the injectate
o The number of mL’s (5mL vs 10mL) --- we use 10 mL of
room temperature injectate for our regular swans, which
requires a computation contant of 0.592
TYPES OF CATHETERS USED FOR HEMODYNAMIC
MONITORING
1. Pulmonary Artery Catheter (Swan Ganz)
2. Arterial Pressure Catheters
3. Central Venous Pressure on CVP monitoring
GENERAL INDICATIONS FOR HEMODYNAMIC
MONITORING
1. Potential or actual alteration in CO
2. Potential or actual alteration in fluid volume
INDICATIONS FOR HEMODYNAMIC MONITORING
 Any deficit or loss of cardiac function: such as AMI, CHF,
cardiomyopathy
 All types of shock: cardiogenic, neurogenic, or anaphylactic
PULMONARY ARTERY MONITORING
1. Invasive catheter (Swan Ganz catheter)
2. Transducer
3. Amplifier/recorder
Effect of Pulmonary Artery Catheterization on
Outcome
 concluded that placement of a PAC during the first 24 hours
of stay in an ICU is associated with a significant increase in
the risk of mortality, even when statistical methods are
used to account for severity of illness
 confirmed the results of two prior similar observational
studies
o Hospital mortality was significantly greater for patients
treated using a PAC, even when multivariate statistical
methods were used to control for key potential
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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

confounding factors such as age, peak circulating mortality or hospital length of stay between the
creatine kinase concentration, and presence or absence patients managed with a PAC and those managed
of new Q waves on the ECG. without a PAC.
o Hospital mortality was significantly greater for patients  ESCAPE trial (which was one of the studies included in the
managed with the assistance of a PAC, even when the previous meta-analysis) evaluated 433 patients with severe
presence or absence of "pump failure" was considered or recurrent congestive heart failure admitted to the ICU
in the statistical analysis. o There was no significant difference in the primary
Summary of Randomized, Prospective Clinical Trials endpoint of days alive and out of the hospital during
Comparing Pulmonary Artery Catheter with Central Venous the first 6 months, or hospital mortality (PAC 10%; vs.
Pressure Monitoring without PAC 9%).
Author Study Groups Outcomes o Adverse events were more common among patients in
Population the PAC group (21.9% vs. 11.5%; P = .04).
Pearson "Low-risk" CVP No differences among  Fluids and Catheters Treatment Trial (FACTT) conducted by
, et al patients catheter groups for mortality or the Acute Respiratory Distress Syndrome (ARDS) Clinical
undergoing (group 1); length of ICU stay;
Trials Network:
cardiac or PAC (group significant differences in
vascular 2); PAC costs (group 1 < group 2 o Mortality during the first 60 days was similar in the
surgery with < group 3) PAC and CVC groups (27% and 26%; P = .69).
continuous o Duration of mechanical ventilation and ICU length of
Sv-O2, stay also were not influenced by the type of catheter
readout used.
(group 3) o Type of catheter used did not affect the incidence of
Tuman, Cardiac PAC; CVP No differences between
shock, respiratory or renal failure, ventilator settings,
et al surgical groups for mortality,
patients length of ICU stay, or or requirement for hemodialysis or vasopressors.
significant noncardiac o Catheter used did not affect the administration of fluids
complications or diuretics, and the fluid balance was similar in the
Bender, Vascular PAC; CVP No differences between two groups.
et al surgery groups for mortality, o PAC group had approximately twice as many catheter-
patients length of ICU stay, or related adverse events (mainly arrhythmias)
length of hospital stay  It is impossible to verify that use of the PAC saves lives
Valentin Aortic PAC + No difference between
when it is evaluated over a large population of patients.
e, et al surgery hemodyna groups for mortality or
patients mic length of ICU stay; Certainly, given the current state of knowledge, routine
optimizatio significantly higher use of the PAC cannot be justified.
n in ICU incidence of postoperative  Based upon the results and exclusion criteria in these
night before complications in PAC prospective randomized trials, reasonable criteria for
surgery; group perioperative monitoring without use of a PAC are
CVP presented in the table below.
Sandha "High-risk" PAC; CVP No differences between
m, et al major groups for mortality, Suggested Criteria for Perioperative Monitoring
surgery length of ICU stay; Without Use of a Pulmonary Artery Catheter in
increased incidence of
Patients Undergoing Cardiac or Major Vascular
pulmonary embolism in
PAC group Surgical Procedures
Harvey, Medical and PAC vs. no No difference in hospital No anticipated need for suprarenal or supraceliac aortic
et al surgical ICU PAC, with mortality between the cross-clamping
patients option for two groups, increased No history of myocardial infarction during 3 mo before
alternative incidence of complications operation
CO in the PAC group
No history of poorly compensated congestive heart failure
measuring
device in No history of coronary artery bypass graft surgery during 6
non-PAC wk before operation
group No history of ongoing symptomatic mitral or aortic valvular
Binanay Patients PAC vs. no No difference in hospital heart disease
, et al with CHF PAC mortality between the No history of ongoing unstable angina pectoris
two groups, increased
 One of the reasons for using a PAC to monitor critically
incidence of adverse
events in the PAC group ill patients is to optimize cardiac output and systemic
Wheeler Patients PAC vs. No difference in ICU or O2 delivery.
, et al with ALI CVC with a hospital mortality, or o Defining what constitutes the optimum cardiac output,
fluid and incidence of organ failure however, has proven to be difficult.
inotropic between the two groups;  Bland et al proposed that "goal-directed"
manageme increased incidence of hemodynamic resuscitation should aim to achieve
nt protocol adverse events in the
a QT greater than 4.5 L/min per square meter and
PAC group
O2 greater than 600 mL/min per square meter
ALI = acute lung injury; CHF = congestive heart failure; CO = cardiac
output; CVC = central venous catheter; CVP = central venous  Some studies provide support for the notion that
pressure; ICU = intensive care unit; PAC = pulmonary artery catheter; interventions designed to achieve supraphysiologic
Sv-O2 = fractional mixed venous (pulmonary artery) hemoglobin goals for O2, O2, and QT improve outcome.
saturation. - Other published studies do not support this
view, and a meta-analysis concluded that
 Recent meta-analysis of 13 randomized studies of the PAC interventions designed to achieve
that included more than 5000 patients supraphysiologic goals for O2 transport do not
o Use of the PAC was associated with an increased use of significantly reduce mortality rates in critically
inotropes and vasodilators, there were no differences in ill patients.

Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta Page 8 of 13

 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

- At this time, supraphysiologic resuscitation of
patients in shock cannot be endorsed
 There is no simple explanation for the apparent lack of
effectiveness of pulmonary artery catheterization.
Several suggestions:
o Even though bedside pulmonary artery catheterization
is quite safe, the procedure is associated with a
finite incidence of serious complications:
 Ventricular arrhythmias
 Catheter-related sepsis
 Central venous thrombosis
 Pulmonary arterial perforation
 Pulmonary embolism
- Adverse effects of these complications on outcome
may equal or even outweigh any benefits
associated with using a PAC to guide therapy
o Data generated by the PAC may be inaccurate,
leading to inappropriate therapeutic interventions.
o Measurements, even if accurate, are often
misinterpreted in practice.
o Current state of understanding is primitive when it
comes to deciding what is the best management for
certain hemodynamic disturbances, particularly those
associated with sepsis or septic shock.
 Taking all of this into consideration, it may be that
interventions prompted by measurements obtained with a
PAC are actually harmful to patients.
o As a result, the marginal benefit now available by
placing a PAC may be quite small.
o Less invasive modalities are available that can provide
clinically useful hemodynamic information.
 It may be true that aggressive hemodynamic resuscitation
of patients, guided by various forms of monitoring, is
valuable only during certain critical periods, such as the
first few hours after presentation with septic shock or
during surgery.
 Distal port – (Yellow) used to measure pulmonary artery
pressure
 Balloon port – (Red) used to determine pulmonary wedge
pressure; 1.5 special syringe is connected
EQUIPMENT NEEDED FOR HEMODYNAMIC MONITORING
EQUIMENT DESCRIPTION
an instrument that senses physiological
Transducer events & transforms them into electrical
signs
connects to transducer end an electrical
Amplifier cable; filters out interference so signal can
be displayed
Monitors provides display of original signal
tubing flush system (single or double):
pressure bag in 500cc Normal Saline with
Catheter 10cc of 100u/ml of heparin; delivers
continuous cc/hr to keep line open; catheter
may be arterial or venous
FUNCTIONS OF COMPONENTS OF THE MONITORING
SYSTEM
 Bedside Monitoring
o amplifier is located inside
o amplifier increases the size of signal
 Transducer
o Changes the mechanical energy or pressures of pulse into
electrical energy
o Should be level with the phlebostatic axis (you can
estimate this by intersecting lines from the 4th ICS, mid
axillary line

COMPONENTS OF A PULMONARY ARTERY CATHETER

The phlebostatic axis, marked on the patient’s chest, is the

precise anatomical point of origin of the hemodynamic
pressure being measure.

POSSIBLE COMPLICATIONS
 Increased risk of infections
o Same as with any central venous lines
o Use occlusive dressing and biopatch to prevent
 Thrombosis and emboli
o Air embolism may occur when the balloon ruptures, clot
on end of catheter can rest in pulmonary embolism
 Catheter wedges permanently
o Considered an emergency, notify MD immediately
o Can occur when balloon is left inflated or catheter
migrates too far into pulmonary artery (flat PA
waveform)………..can cause pulmonary infarct after only a
few minutes
 Ventricular irritation
o Occurs when catheter migrates back into RV or is looped
through the ventricles, notify MD immediately

SWAN GANZ CATHETER

a. Distal Lumen: the PA (pulmonary artery)
b. Proximal Lumen: (CVP port)
c. Inflation Balloon
 Normally has four (4) ports d. Thermostat Lumen
 Proximal port – (Blue) used to measure central venous e. Additional Lumens
pressure/RAP and injectate port for measurement of cardiac
output

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS
MINIMALLY INVASIVE ALTERNATIVES TO THE
PULMONARY ARTERY CATHETER
1. DOPPLER ULTRASONOGRAPHY
 Doppler shift – Increase or decrease in the frequency of
ultrasonic sound waves reflected by moving erythrocytes
depending on the direction of movement
 Magnitude – velocity of moving RBCs
 Flow rate (QT) = HR X A X ∫V(t)dt (HR heart rate; A cross-
sectional area of vessel; V velocity of flowing blood)
Approaches to Estimate QT
Ultrasonic transducer
 Placed in sternal notch, focused on root of aorta
 Aortic X.S. area estimated using (1) nomogram, or (2)
tranthoracic or (3) transesophageal ultrasonography
 Accuracy is NOT acceptable – used only for intermittent QT
estimates
Continuous-wave Doppler transducer
 Introduced 35 cm from incisors into the esophagus in
sedated patients to continuously monitor blood flow velocity
in the descending thoracic aorta
 Nomogram is used to estimate aortic x.s. area
 Flow time corrected (FTc) = systolic flow time in descending
aorta, measured as a function of preload, contractility, and
vascular input impedance
 Reasonably accurate
2. IMPEDANCE CARDIOGRAPHY
 Bioimpedance – impedance to blood flow of alternating
electrical current in regions of the body
 Impedance cardiography – estimate SV and QT on the
basis of linear relationship of aortic blood flow and first
derivative of oscillating component of thoracic
bioimpedance
 NOT sufficiently reliable – not recommended for
hemodynamic monitoring of critically ill patients
3. PULSE CONTOUR ANALYSIS
 Determines cardiac output by estimating SV on beat-to-
beat basis
 QT estimation uses arterial pressure waveform
 Resistance, compliance, and impedance are initially
estimated based on age and sex
 Reference standard QT is obtained using indicator dilution
injected into CVC
 Computerized algorithms calculate SV, QT, SVR, myocardial
contractility, rate of rise of arterial systolic pressure
Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta
 Applied using noninvasive photoplethysmographic
measurement of arterial pressure
 Accuracy questionable
4. PARTIAL CO2 REBREATHING
 Uses Fick principle to estimate QT
 Dead space within ventilator circuit is altered via a
rebreathing valve  changes in CO2 production (VCO2) and
end-tidal CO2 (ETCO2)  determine cardiac output: QT =
∆VCO2/ ∆ETCO2 (modified Fick equation)
 Parts:
o CO2 sensor – based on infrared light absorption
o Airflow sensor
o Pulse oximeter
 Impaired accuracy with changes in intrapulmonary shunt
and hemodynamic instability
o Corrected using continuous in-line pulse oximetry and
inspired fraction of inspired O2
5. TRANSESOPHAGEAL ECHOCARDIOGRAPHY
 Patient must be sedated and intubated for airway
protection
 For assessments of LV and RV function, ventricular volume,
EF, QT
 For identifying segmental wall motion abnormalities,
pericardial effusions, and tamponade
 Atrial filling pressures estimated using Doppler techniques
ASSESSING PRELOAD RESPONSIVENESS
 Adequacy of cardiac output assessed by determining CVP or
PAOP
 However, CVP and PAOP does not correlate well with left-
ventricular end-diastolic volume (LVEDV) and SV
 Extremely high or low CVP or PAOP are informative, but not
between 5 and 20 mmHg
 Application of positive airway pressure  ↑intrathoracic
pressure  ↓venous return  ↓LVSV  pulse pressure
variation (PPV) can predict CO responses to changes in
preload
o PPV – best predictor of preload responsiveness
o Usefulness interfered by atrial arrhythmias
 PPV = (max. pulse pressure – min. pulse pressure)/(ave. of
max. and min. PP)
 Preload responsive – cardiac index ↑ by at least 15% after
rapid infusion of standard volume of IV fluid
TISSUE CAPNOMETRY
 Global indices of QT, DO2, or VO2 provide useful info on
adequacy of cellular oxygenation and mitochondrial
function
 Tissue pH for assessment of adequacy of perfusion
o ↓oxygenation (perfusion)  anaerobiosis  ↓pH
Capnometry of GI Mucosa
 Tonometric measurement of tissue PCO2 of stomach or
sigmoid – estimate mucosal pH (pHi), hence monitor
visceral perfusion
 Henderson-Hasselbach equation: calculating pHi to
determine PCO2muc
pHi = log([HCO3-]muc/0.03xPCO2muc)
where:
o [HCO3-] is estimated with the assumption that [HCO3-
]art ≈ [HCO3-]muc under normal conditions;
o PCO2muc reflects balance between CO2 inflow into and
outflow from interstitial space (inflow via diffusion from
arterial blood, production in aerobic metabolism, and
production as a result of HCO3= titration; outflow via
diffusion)
 Problems:
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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS

o [HCO3-]art not always ≈ [HCO3-]muc e.g., when blood DETERMINANTS OF OXYGEN DELIVERY
flow to ileal mucosa is ↓  Primary goal of CVS and Respiratory system is the delivery
o [HCO3-]art also affected by diabetic ketoacidosis, of Oxygenated blood to tissues
iatrogenic alkalinization)  O2 is dependent on O2 saturation of Hgb in arterial blood
o ↑PCO2 can also be caused by arterial hypercarbia (SaO2) than on partial pressure of O2 in arterial blood
(PaO2)
Advantages of GI Mucosa Capnometry  Also dependent on QT and Hgb
 In compromised global perfusion, blood flow to splanchnic  SaO2 in mechanically ventilated patients depend on the ff.
viscera ↓ to greater extent o mean airway pressure
 Gut is the motor of the MODS, and is associated with o FiO2 --fraction of inspired O2
hyperpermeability to hydrophilic solutes o SvO2 -- O2saturation in venous blood
 Remarkable predictor of outcome in critically ill individuals
 Development of gastric mucosal acidosis correlates with PEAK AND PLATEAU AIRWAY PRESSURE
mucosal hypoperfusion  Peak Airway Pressure (Ppeak)
 Normalization of pHi was associated with significantly o Measured at end of inspiration
low mortality rate (7%) o Function of:
 Tidal volume
Disadvantages Stomach Capnometry  Resistance of airways
 CO2 can be formed in the lumen when H+ are secreted by  Lung/chest wall compliance
parietal cells, hence confounding PCO2 and pHi  Peak inspiratory flow
 Enteral feeding interferes with measurements of PCo2  Plateau airway pressure (Pplateau)
o airway pressure measured at the end of inspiration
Tissue capnometry in sublingual mucosa when the inhaled volume is held in the lungs by
 ↑PslCO2 associated with ↓arterial blood pressure and QT in briefly closing the expiratory valve
shock patients o independent of airway resistance and peak airway flow
 In patients with septic or cardiogenic shock, PslCO 2 – PaCO2 o related to the lung/chest wall compliance and delivered
gradient is a good prognostic indicator tidal volume
o Survivors: 9.2 ± 5.0 mmHg decrease in the compliance in the
Ppeak & Pplateau INCREASED
o Nonsurvivors: 17.8 ± 11.5 mmHg lung/chest wall unit
 Superior to gastric tonometry in predicting patient survival Ppeak is INCREASED primary problem is an increase in
 PslCO2 – PaCO2 gradient – better marker of tissue hypoxia Pplateau relatively NORMAL airway resistance
it suggests a discontinuity in the
NEAR INFRARED SPECTROSCOPIC (NIRS) Ppeak LOW airway circuit involving the
MEASUREMENT OF TISSUE HEMOGLOBIN OXYGEN patient and the ventilator
SATURATION  barotrauma – subjecting lung parenchyma to excessive
 allows continuous, noninvasive measurement of tissue Hgb pressure, a ventilator-induced lung injury
O2 saturation (StO2)  pts with ARDS – standard of care is through monitoring of
 uses wavelength 700-1000 nm Pplateau and using Low tidal volume strategy
 based on Beer’s law, where transmission of light through a
solution is indirectly proportional to the dissolved solute PULSE OXIMETRY
(exponential)  Continuous non-invasive monitoring of arterial oxygen
 measurements primarily indicative of the venous saturation
oxyhemoglobin concentration  provides continuous noninvasive monitoring of SaO2
 considered one of the most important and useful
RESPIRATORY MONITORING technologic advances in patient monitoring
 uses LED and sensors placed on the skin
ARTERIAL BLOOD GASES (ABG)
 intermittent measurements of ABG is the standard for CAPNOMETRY
respiratory monitoring  Measurement of PCO2 in the airway throughout the
 useful information for patients with respiratory failure and respiratory cycle
in the detection of alterations in acid-base balance due to  most commonly measured by infrared light absorption
low QT, sepsis, renal failure, severe trauma, medication or  CO2 absorbs infrared light at a peak
drug overdose, or altered mental status  works by passing infrared (IR) light through a sample
 Arterial blood can be analyzed for pH, PO2, PCO2, HCO3– chamber to a detector on the opposite side.
concentration, and calculated BD  More IR passing through the sample chamber (i.e. less
 Intermittent arterial blood gas determination vs. continuous CO2) causes a larger signal in the detector relative to the
bedside ABG determination  excellent agreement between IR light passing through reference cell
the two methods (however, intermittent removal of an  Capnography allows the confirmation of endotracheal
aliquot of blood is cheaper) intubation and continuous assessment of ventilation,
integrity of the airway, operation of the ventilator, and
Arterial Venous cardiopulmonary function
pH 7.35 - 7.45 7.32 - 7.42
PaO2 80 to 100 mm Hg 28 - 48 mm Hg RENAL MONITORING
HCO3 22 to 26 mEq/liter 19 to 25 mEq/liter
(21–28 mEq/L) URINE OUTPUT
PaCO2 35-45 mm Hg 38-52 mm Hg  bladder catheterization with an indwelling catheter allows
the monitoring of urine output, usually recorded hourly by
the nursing staff

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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS
 with a patent Foley catheter, urine output is a gross
indicator of renal perfusion.
 generally accepted normal urine output:
o 0.5 mL/kg per hour for adults
o 1 to 2 mL/kg per hour for neonates and infants
 oliguria may reflect inadequate renal artery perfusion due
to hypotension, hypovolemia, or low QT
 low urine flow also can be a sign of intrinsic renal
dysfunction
 it is important to recognize that normal urine output does
not exclude the possibility of impending renal failure
BLADDER PRESSURE
ABDOMINAL COMPARTMENT SYNDROME (ACS)
 triad of oliguria, elevated peak airway pressures, and
elevated intra-abdominal pressure
 first described in patients after repair of ruptured abdominal
aortic aneurysm
 associated with interstitial edema of the abdominal organs,
resulting in elevated intra-abdominal pressure
 when intra-abdominal pressure exceeds venous or capillary
pressures, perfusion of the kidneys and other intra-
abdominal viscera is impaired
 oliguria is a cardinal sign
 although the diagnosis of ACS is a clinical one, measuring
intra-abdominal pressure is useful to confirm the diagnosis
 ideally, a catheter inserted into the peritoneal cavity could
measure intra-abdominal pressure to substantiate the
diagnosis
 in practice, transurethral bladder pressure
measurement reflects intra-abdominal pressure and is
most often used to confirm the presence of ACS
 after instilling 50 to 100 mL of sterile saline into the bladder
via a Foley catheter, the tubing is connected to a
transducing system to measure bladder pressure
 most authorities recommend that a bladder pressure
greater than 20 to 25 mmHg confirms the diagnosis of ACS
 less commonly, gastric or inferior vena cava pressures can
be monitored with appropriate catheters to detect elevated
intra-abdominal pressures
NEUROLOGIC MONITORING
INTRACRANIAL PRESSURE
 because the brain is rigidly confined within the bony skull,
cerebral edema or mass lesions increase intracranial
pressure (ICP)
 To detect and treat abnormal elevations of ICP that may be
detrimental to cerebral perfusion and function
 monitoring of ICP is currently recommended:
o in patients with severe traumatic brain injury (TBI),
defined as a Glasgow Coma Scale (GCS) score ≤8 with
an abnormal CT scan
o in patients with severe TBI and a normal CT scan if two
or more of the following are present:
 age greater than 40 years
 unilateral or bilateral motor posturing
 systolic blood pressure less than 90 mmHg
 ICP monitoring also is indicated in patients with:
o acute subarachnoid hemorrhage with coma or neurologic
deterioration
o intracranial hemorrhage with intraventricular blood
o ischemic middle cerebral artery stroke
o fulminant hepatic failure with coma and cerebral edema
on CT scan
o global cerebral ischemia or anoxia with cerebral edema
on CT scan
Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta
 goal of ICP monitoring is to ensure that cerebral
perfusion pressure (CPP) is adequate to support
perfusion of the brain
 CPP is equal to the difference between MAP and ICP:
o CPP = MAP – ICP
 ventriculostomy catheter
o one type of ICP measuring device
o consists of a fluid-filled catheter inserted into a cerebral
ventricle and connected to an external pressure
transducer
o this device permits measurement of ICP, but also allows
drainage of cerebrospinal fluid (CSF) as a means to lower
ICP and sample CSF for laboratory studies
o are the accepted standard for monitoring ICP in
patients with TBI due to their accuracy, ability to
drain CSF, and low complication rate
o associated complications include infection (5%),
hemorrhage (1.4%), catheter malfunction or obstruction
(6.3 to 10.5%),& malposition w/injury to cerebral tissue
 other devices locate the pressure transducer within the
central nervous system and are used only to monitor ICP
 these devices can be placed in the intraventricular,
parenchymal, subdural, or epidural spaces
 purpose of ICP monitoring is to detect and treat
abnormal elevations of ICP that may be detrimental
to cerebral perfusion and function
 in TBI patients, ICP greater than 20 mmHg is associated
with unfavorable outcomes
 however, few studies have shown that treatment of
elevated ICP improves clinical outcomes in human trauma
patients
 in a randomized, controlled, double-blind trial, Eisenberg
and colleagues demonstrated that maintaining ICP less
than 25 mmHg in patients without craniectomy and less
than 15 mmHg in patients with craniectomy is associated
with improved outcome
 in patients with low CPP, therapeutic strategies to correct
CPP can be directed at increasing MAP or decreasing ICP
 although it often has been recommended that CPP be
maintained above 70 mmHg, the evidence to support this
recommendation is not overly compelling
 furthermore, a retrospective cohort study of patients with
severe TBI found that ICP/CPP-targeted neurointensive care
was associated with prolonged mechanical ventilation and
increased therapeutic interventions, without evidence for
improved outcome in patients who survive beyond 24 h
ELECTROENCEPHALOGRAM AND EVOKED POTENTIALS
 electroencephalography offers the capacity to monitor
global neurologic electrical activity
 evoked potential monitoring can assess pathways not
detected by the conventional electroencephalogram (EEG)
 continuous EEG (CEEG) monitoring
o in the ICU, it permits ongoing evaluation of cerebral
cortical activity
o it is especially useful in obtunded and comatose patients
o is useful for monitoring of therapy for status epilepticus &
detecting early changes associated with cerebral ischemia
o can be used to adjust the level of sedation, especially if
high-dose barbiturate therapy is being used to manage
elevated ICP
 somatosensory and brain stem evoked potentials are less
affected by the administration of sedatives than is the EEG
 evoked potentials
o are useful for localizing brain stem lesions or proving the
absence of such structural lesions in cases of metabolic
or toxic coma
o they also can provide prognostic data in posttraumatic
coma
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 PRE- AND POST-OPERATIVE CARE AND MONITROING OF SURGICAL PATIENTS
 bispectral index (BIS)
o a recent advance in EEG monitoring
o used to titrate the level of sedative medications
o although sedative drugs usually are titrated to the clinical
neurologic examination, the BIS device has been used in
the operating room to continuously monitor the
depth of anesthesia
o an empiric measurement statistically derived from a
database of more than 5000 EEGs
o derived from bifrontal EEG recordings and analyzed for
burst suppression ratio, relative alpha:beta ratio, and
bicoherence
o using a multivariate regression model, a linear numeric
index (BIS) is calculated, ranging from 0 (isoelectric EEG)
to 100 (fully awake)
o its use has been associated with lower consumption
of anesthetics during surgery and earlier
awakening and faster recovery from anesthesia
o BIS also has been validated as a useful approach for
monitoring the level of sedation for ICU patients,
using the revised Sedation-Agitation Scale as a
gold standard
TRANSCRANIAL DOPPLER (TCD) ULTRASONOGRAPHY
 provides a noninvasive method for evaluating cerebral
hemodynamics
 measurements of middle and anterior cerebral artery blood
flow velocity are useful for the diagnosis of cerebral
vasospasm after subarachnoid haemorrhage
 Qureshi and associates demonstrated that an increase in
the middle cerebral artery mean flow velocity as assessed
by TCD is an independent predictor of symptomatic
vasospasm in a prospective study of patients with
aneurysmal subarachnoid haemorrhage
 in addition, while some have proposed using TCD to
estimate ICP, studies have shown that TCD is not a reliable
method for estimating ICP and CPP, and currently cannot
be endorsed for this purpose
 TCD also is useful to confirm the clinical examination
for determining brain death in patients with
confounding factors such as the presence of central
nervous system depressants or metabolic encephalopathy
JUGULAR VENOUS OXIMETRY
 when the arterial O2 content, Hgb concentration, and the
oxyhemoglobin dissociation curve are constant, changes in
jugular venous O2 saturation (SjO2) reflect changes in the
difference between cerebral O2 delivery and demand
 a decrease in SjO2  cerebral hypoperfusion
 an increase in SjO2  presence of hyperemia
 SjO2 monitoring can’t detect decreases in regional cerebral
blood flow if overall perfusion is normal or above normal
 this technique requires the placement of a catheter in the
jugular bulb, usually via the internal jugular vein for
measurement of SjO2
 catheters that permit intermittent aspiration of jugular
venous blood for analysis or continuous oximetry catheters
are available
 low SjO2 is associated with poor outcomes after TBI
 the value of monitoring SjO2 remains unproven
 if it is used, it should not be the sole monitoring technique,
but rather should be used in conjunction with ICP and CPP
monitoring
 by monitoring ICP, CPP, and SjO2, early intervention with
volume, vasopressors, and hyperventilation has been
shown to prevent ischemic events in patients with TBI
TRANSCRANIAL NEAR INFRARED SPECTROSCOPY
Agatep, Detera, Doong, Rodriguez, Tejano, Villacorta
 a noninvasive continuous monitoring method to
determine cerebral oxygenation
 it uses technology similar to that of pulse oximetry to
determine the concentrations of oxy- and deoxyhemoglobin
with near infrared light and sensors, and takes advantage
of the relative transparency of the skull to light in the near
infrared region of the spectrum
 McCormick and associates demonstrated that cerebral
desaturation can occur more than 2 hours before any
clinical deterioration in neurologic status
 this form of monitoring remains largely a research tool at
the present time
BRAIN TISSUE OXYGEN TENSION
 although the standard of care for patients with severe TBI
includes ICP and CPP monitoring, this strategy does not
always prevent secondary brain injury
 growing evidence suggests that monitoring local brain
tissue O2 tension (PbtO2) may be a useful adjunct to ICP
monitoring in these patients
 normal values for PbtO2 are 20 to 40 mmHg
 critical levels for PbtO2 are 8 to 10 mmHg
 a recent clinical study sought to determine whether the
addition of a PbtO2 monitor to guide therapy in severe TBI
was associated with improved patient outcomes
o twenty-eight patients with severe TBI (GCS score ≤8)
were enrolled in an observational study at a level I
trauma center
o these patients received invasive ICP and PbtO 2
monitoring and were compared with 25 historical controls
matched for age, injuries, and admission GCS score that
had undergone ICP monitoring alone
o goals of therapy in both groups included maintaining an
ICP <20 mmHg and a CPP >60 mmHg
o among patients with PbtO2 monitoring, therapy also was
directed at maintaining PbtO2 >25 mmHg
o groups had similar mean daily ICP and CPP levels
o mortality rate in the historical controls treated with
standard ICP and CPP management was 44%
o mortality was significantly lower in the patients who had
therapy guided by PbtO2 monitoring in addition to ICP
and CPP (25%; P <.05)
 benefits of PbtO2 monitoring may include the early
detection of brain tissue ischemia despite normal ICP
and CPP
 PbtO2-guided management may reduce potential
adverse effects associated with therapies to maintain
ICP and CPP
CONCLUSIONS
 modern intensive care is predicated by the need and
ability to continuously monitor a wide range of
physiologic parameters
 this capability has dramatically improved the care of
critically ill patients and advanced the development of the
specialty of critical care medicine
 in some cases, the technologic ability to measure such
variables has surpassed our understanding of the
significance or the knowledge of the appropriate
intervention to ameliorate such pathophysiologic changes
 in addition, the development of less invasive
monitoring methods has been promoted by the
recognition of complications associated with invasive
monitoring devices
 the future portends the continued development of
noninvasive monitoring devices along with their application
in an evidenced-based strategy to guide rational therapy
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