M8 - Investigations and Monitoring in The ICU

Certificate in Critical Care Medicine
Video Script
Introduction to the Respiratory system
Learning Objectives
At the end of this topic, you will be able to:
 Describe the physiology of the respiratory system and

 Explain the mechanism involved in the physiology of the respiratory system
Introduction
The respiratory system plays a key role by incorporating the oxygen in the environment. It includes the utilization
of energy from the organic compounds and the elimination of carbon dioxide. Lungs are considered as a pair of
air-filled spongy organs located on either side of the chest. They are the primary organs of respiration. Each lung
has approximately 200 to 300 million alveoli, with a total surface area of 140 meter square available for exchange
of gases.
Lung Volumes and Ventilation
Let’s get started with the Lung Volumes and Ventilation.
There are 23 generations of airway tubes that lead to the alveoli. The first generation starts at trachea and ends in
the 23rd generation near terminal bronchiole. Surface area of the respiratory tract equals to about 2.5 centimeter
square at the trachea, rapidly increasing to 70 centimeter square at the 14th and to 8000 centimeter square at the
23rd generation of tubes entering the acini.
Let’s get started with the Lung Volumes and Ventilation.
There are 23 generations of airway tubes that lead to the alveoli. The first generation starts at trachea and ends in
the 23rd generation near terminal bronchiole. Surface area of the respiratory tract equals to about 2.5 centimeter
square at the trachea, rapidly increasing to 70 centimeter square at the 14th and to 8000 centimeter square at the
23rd generation of tubes entering the acini.
Ordinary breath travels with an average velocity of about 0.7 meters per second along the trachea. Maximum
inspiration gas volume in the whole lung equals 6 to 8 liters in normal conditions. Residual volume is the volume
of retained gas and equals 2 to 2.5 liters.
Vital capacity is the maximum air volume that can be inspired, and then expired in a breath and has a value of 4-6
liters. Functional residual capacity is the volume of retained air inside the lung and equals to about 3-4 liters.
Compliance of the Respiratory System
Now let’s take a look at the compliance of the Respiratory System.
Compliance of the respiratory system is a property exhibited by both the lungs and the chest wall. Elastic recoil of
the lungs keeps them inflated, where the pressure inside the alveoli needs to exceed the intrapleural pressure.
Normal lung compliance is 0.2 – 0.3 liters per centimeter of water. Values increase in emphysema and decreases
in restrictive pulmonary diseases (for example, pulmonary fibrosis) and general anesthesia.
Resistance of the Respiratory System
Let’s now understand the resistance of the Respiratory System.
The respiratory system resistance is formed together by the airways, lung tissue and chest wall. The table
displayed explains the resistance of the respiratory system in terms of gas flow direction, flow speed and
resistance force in larger airways and smaller airways. The gas flow direction in larger airways is tubular and in
smaller airways it is laminar. The gas flow speed is directly proportional with the squared pressure in larger
airways and shows a direct linear relationship with pressure. The resistance force forms most of the resistance
forms in larger airways and is about 20% in smaller airways.
Inspired Gas Diffusion
The inspired air goes down towards the most dependent regions in the lungs.
• The regions and positions include:
• Basal diaphragmatic regions in the upright and sitting positions
• Dorsal regions in the supine position and left lung region in the left lateral position
Increase in the flow rate of inspired air makes air to go the upper non-dependent regions of lung.
Airway Closure
The inspired air goes down towards the most dependent regions in the lungs.
• The regions and positions include:
• Basal diaphragmatic regions in the upright and sitting positions
• Dorsal regions in the supine position and left lung region in the left lateral position
Increase in the flow rate of inspired air makes air to go the upper non-dependent regions of lung.
Diffusion of Gases
Diffusion of gases is the process of movement of gases oxygen and carbon dioxide between the alveolar space
and alveolar blood. Oxygen moves passively from the alveolar space into the alveolar blood where it combines
with hemoglobin. Diffusion of gases is decreased in cases of lung fibrosis and emphysema.
Pulmonary Perfusion (Pressure-flow Relationship) Dif
Now’s lets discuss the pulmonary perfusion (Pressure-flow Relationship)
Pulmonary circulation is considered as a low-pressure system.
The pulmonary artery pressure is 20 by 80 millimeters of mercury. This is because pulmonary vessels have a wide
diameter, and a shorter length than systemic vessels.
The decreased pressure leads to a decreased resistance with effects like pulmonary capillary flow is pulsatile,
unlike steady systemic capillary flow.
Alveolar, and capillary walls can be very thin without any plasma leakage facilitating gas diffusion in both
directions. When the pressure goes up, pulmonary edema develops easily.
Distribution of Lung Blood Flow
Now let’s take a quick look at the distribution of lung blood flow.
• Distribution of lung blood flow follows the property of gravity force.
• The Pulmonary Arterial Pressure or PAP increases by going towards more dependent regions by about 1
centimeter H2O per centimeter distance and,
• Depending on the height of the lung, the pulmonary arterial pressure difference between the upper and lower
regions is 11 to 15 millimeters of mercury.
Hypoxic pulmonary vasoconstriction (HPV)
Hypoxic pulmonary vasoconstriction (HPV) reduces blood flow in hypoxic lung regions.
The strength of the constriction is dependent on the size of the lung segment exposed to hypoxia. The major
stimulus is a low level of alveolar oxygen tension, caused either by hypoventilation or by breathing gas with a low
partial pressure of oxygen or PO2. Chronic lung disease with hypoxemia also causes HPV.
Physiology of the respiratory system helps in the management of patients in the intensive care unit.
Video Script
Capnography
Learning Objectives
By the end of this topic, you will be able to:
 Discuss the importance of capnography and

 Explain the different phases of end-tidal carbon dioxide time tracing
Introduction
Capnography is an essential clinical tool that should be used with all sedated or intubated patients. It was first
started in 1865, introduced into clinical practice in the early fifties and it is now considered as a routine monitoring
for all patients on mechanical ventilation. Capnometry is the measurement of carbon dioxide concentration in a
gas mixture, while capnography is the continuous waveform display of the capnometer data throughout the
ventilatory cycle.
Value of Information Obtained from Capnography
Let’s now understand the value of information obtained from capnography.
The continuous non-invasive information provided by capnography can help a physician with many situations,
which include:
 The intra-airway position of the endotracheal tube or ETT followed by intubation.

 The mis-insertion of the nasogastric tube into the airway
 In cases of development of apnea, bronchospasm continuous capnographic data act as an instant alarm
 Monitoring of effectiveness of cardiopulmonary resuscitation or CPR), and air embolism
Phases Visible on the End-Tidal Carbon Dioxide Time Tracing
There are four phases visible on the End-tidal carbon dioxide (PET CO2 )time tracing.
Now let’s understand each of these four phases in detail.

Phase 1 includes expiration of carbon dioxide free gas from anatomical dead space, upper airway to bronchi.
Phase II includes mixed gas from airways and alveoli
Phase III includes alveolar plateau of gas from alveoli, rising slightly due to variable mixing and time constants.
Phase 0 is represented as a Sharp descent and it is due to the absence of carbon dioxide in inspired gas.
Various Conditions affecting Carbon Dioxide Production
Now let’s understand various conditions that affect carbon dioxide production:
• Fever, parenteral nutrition, malignant hyperthermia, thyrotoxicosis, tourniquet release, and bicarbonate
infusion increase the carbon dioxide production
• Hypothermia, and sedation decrease the carbon dioxide production.
Changes in Dead Space Ventilation
Now let’s understand the changes occurring during the Dead Space Ventilation.
The changes include:
 Shock, cardiac arrest, air embolism and pulmonary embolism

 The gap between PET CO2 and partial pressure of carbon dioxide (PaCO2) is called CO2 gradient, and is
usually less than 5 millimeters of mercury (and 0.67 kilopascal).
 It may be greater than 15 millimeters of mercury (1.99 kilopascal) in situations that increase the
physiological dead space
Errors in Capnography
• Technical problems
• Blocked sensor window
• Blocked sampling tube or
• Delay in achieving a trace
Common Abnormal Patterns

Now let's explore the common abnormal patterns of capnography.
These include:
 Elevated Phase 1
 Decreased Phase II slope
 Absent Phase III plateau
 Elevated Postapneic End-Tidal Carbon Dioxide Pressure or PETCO2
Let’s discuss each of these phases in detail.
• Elevated Phase 1: this might be due to rebreathing, incompetent circuit valves, exhausted CO 2 absorber during
anesthesia, low fresh gas flow, or slow side stream sampling rate.
• Decreased Phase II slope: this might be due to slow side stream sampling rate, kinked or blocked endotracheal
tube, or expiratory obstruction.
• Absent Phase III plateau: this might be due to in COPD or chronic obstructive pulmonary disease,
bronchospasm, or acute respiratory distress syndrome or ARDS.
• Elevated PETCO2: this might be due to hypoventilation, malignant hyperthermia.
Summary
Capnography is considered as an indispensable tool for monitoring metabolic and respiratory function. Its
application is increasing in many emergency situations such as patients undergoing mechanical ventilation,
pulmonary disease, shock, metabolic disorder and trauma and so on.
Video Script
Blood Gas Analysis
Learning Objectives
 Assess the ventilation and acid-base disturbances and,

 Explain the schematic approach to interpretation of blood gases in detail
Introduction
Arterial Blood Gases or ABG interpretation is an essential clinical tool. It reveals about acid-base status, patient’s
oxygenation, and its concentration. An ABG sample is taken from arterial blood, usually radial or femoral arteries,
immediately mixed with an anticoagulant present in the container to prevent clotting. The most basic set of
information in an ABG sheet are the pH, the partial pressure of oxygen or PaO 2, and the partial pressure of carbon
dioxide or PaCO2.
A co-oximeter helps to measure hemoglobin content, hemoglobin oxygen saturation or SaO2, and carbon
monoxide hemoglobin or COHb and methemoglobin or MetHb saturation.
Normal Ranges of Gases
Before moving into the blood gas analysis, let us look at the normal values of various gases.
The following table illustrates about the normal ranges of various gases.
These include partial pressure of oxygen or PaO2, hemoglobin oxygen saturation or SaO2 and so on.
Assessment of Oxygenation
Let’s now talk about the assessment of oxygenation in detail.
Partial pressure of oxygen or PaO2 in a healthy individual shouldn’t be any less than 10 kilopascal. If the patient
is receiving oxygen flow, he is expected to have a PaO2 of 10 Kilo Pascal less than the percentage of the inspired
oxygen concentration.
 A PaO2 less than 10 kilopascal indicates hypoxemia, and less than 8Kilopascal indicates severe hypoxemia.
Severe hypoxemia with hypercapnia (that is PaCO2 greater than 6 kilopascal) indicates respiratory failure
type2.
 Severe hypoxemia with normocapnia (PaCO2 less than 6.0 kilopascal) indicates respiratory failure type 1.
Now let’s understand the assessment of oxygenation in detail.
A ratio of partial pressure arterial oxygen to fraction of inspired oxygen can be used to assess oxygenation. A ratio
less than 300 is consistent with acute lung injury or ALI, while a ratio less than 200 is consistent with acute
respiratory distress syndrome or ARDS. Hypoxemia can be caused by several physio-pathological states.
Assessment of Ventilation and Acid-Base Disturbances
Coming to the Assessment of ventilation and acid-base disturbances:
Ventilation should always be assessed in combination with acid-base status. For instance, a rise in PaCO2 indicates
alveolar hypoventilation, while a decrease indicates alveolar hyperventilation. To maintain a normal pH,
functioning homeostatic mechanisms result in metabolic acidosis triggering a compensatory hyperventilation and
metabolic alkalosis, a compensatory reduction in ventilation.
A pH represents a negative logarithmic value. For example, a solution with a pH measuring 3 has 10 times more
Hydrogen ions than a solution with a pH of 4, and 100 times more hydrogen ions than a solution with a pH of 5.
A normal pH varies between 7.35 – 7.45. An abnormal pH, whether Acidotic: pH less than 7.35, or Alkalotic: pH
greater than 7.45 is a stimulus to consider the causes behind this imbalance.
This table illustrates the partial pressure of carbon dioxide or PaCO2 values to determine the primary cause of the
imbalance. These include conditions such as respiratory acidosis, respiratory alkalosis, respiratory acidosis with
metabolic compensation and respiratory alkalosis with metabolic compensation. For instance, during the
respiratory acidosis with metabolic compensation, the pH is decreased and over the time becomes normal, and
carbon dioxide is increased, and bicarbonate ion level increases.
This table illustrates the pH, carbon-dioxide and bicarbonate ion changes during the acid-base disturbances. These
include conditions such as metabolic acidosis, metabolic alkalosis, metabolic acidosis with respiratory
compensation and metabolic alkalosis with respiratory compensation. For instance, during the metabolic alkalosis
with respiratory compensation, the pH, bicarbonate ion level and the carbon dioxide gets increased.
Base Excess
Let’s now talk about the base excess.
• A base excess lower than -2 millimoles per litre indicates a below-normal bicarbonate ion concentration,
which is due to primary metabolic acidosis or a compensated respiratory alkalosis.
• A base excess more than +2 millimoles per litre indicates an above-normal bicarbonate ion concentration,
which is due to a primary metabolic alkalosis or a compensated respiratory acidosis.
Anion Gap
Coming to the concept of Anion gap,
The Anion gap is a derived value used to determine the presence of unmeasured anions in cases of metabolic
acidosis. Normally, there are equivalent amounts of cations, and anions in the extracellular space. The remaining
unmeasured cations in the extracellular fluid are sulfates, and phosphates. Chloride, and bicarbonate represent the
main bulk of the extracellular anions, along with other unmeasured anions.
Schematic Approach to Interpretation of Blood Gases
Here is a schematic approach to interpretation of blood gases.
An ABG sample is drawn with certain precautions and analyzed by an ABG analyzer. Assess the pH level. A pH
level of less than 7.35 indicates acidosis, while of greater than 7.45 indicates alkalosis. Once a diagnosis of
metabolic acidosis or alkalosis is established, its subtype is determined as illustrated in the table. For instance, the
Urinary chloride level, and patient’s central venous pressure are considered to determine type of metabolic
alkalosis.
This table describes the factors determining the chloride responsive metabolic alkalosis. For instance, patient is
frequently hypovolemic and has chloride levels less than 10 millimoles per litre in case of metabolic alkalosis.
The patient usually responds well to treatment with chloride-containing solutions.
Chronic-Responsive Metabolic Alkalosis

Coming to chronic-responsive metabolic alkalosis,
This table describes the factors determining the chloride responsive metabolic alkalosis. For instance, patient is
frequently hypovolemic and has chloride levels less than 10 millimoles per litre in case of metabolic alkalosis.
The patient usually responds well to treatment with chloride-containing solutions.
Chloride-Resistant Metabolic Acidosis
Moving to chloride-resistant metabolic acidosis,
The table describes about the factors determining the chloride-resistant metabolic alkalosis.
Here, patients are usually hypervolemic or normovolemic and have urinary chloride levels as greater than 10 mmol
per liter in case of metabolic alkalosis. Here, patient doesn’t respond well to treatment with chloride. Treatment
of the cause is the most effective strategy for this type of metabolic alkalosis.
Causes of Metabolic Acidosis
Let’s take a closer look at the causes of metabolic acidosis.
Here is the table that illustrates about the different causes of the anion gap metabolic acidosis. These include:
 Ketoacidosis
 Lactic acidosis
 Uremia and,
 Acute toxin ingestion
This table illustrates the different causes of the Non-anion gap metabolic acidosis.
 Pancreatic drainage
 Biliary drainage
 Diarrhea and
 Urinary diversion
Causes of Respiratory Acidosis
Moving to causes of respiratory acidosis,
The above table illustrates about the different causes of the Respiratory acidosis. The Upper airway obstruction
includes Posterior tongue displacement, and laryngospasm, foreign body inhalation, and aspiration and
neuromuscular disorders include prolonged depolarizing and non –depolarizing blockade.
Other causes of respiratory acidosis include lower airway obstruction such as obstructive sleep apnea, and severe
bronchospasm and Neuromuscular disorders.
Here is the continuation of some other causes of respiratory acidosis. These include restrictive lung disease like
hemothorax, pneumothorax and acute lung injury, Respiratory center depression and other causes of increased
carbon-dioxide like malignant hyperthermia and maladjusted mechanical ventilation.
Causes of Chloride-Responsive Metabolic Alkalosis
Let us now look into the causes of Chloride-Responsive Metabolic Alkalosis
This table illustrates the causes of Chloride-Responsive Metabolic Alkalosis such as:
 Diuretics
 Severe vomiting
 Severe diarrhea and,
 Frequent nasogastric tube suction.
Chloride-Resistant Metabolic Alkalosis
Here are the causes of chloride-resistant metabolic alkalosis.
This table illustrates about the causes of chloride-resistant metabolic alkalosis such as:
 Hyperaldosteronism
 Cushing syndrome
 Batter’s syndrome
 Thiazide or loop diuretics and,
 Excessive potassium supplementation
Causes of Respiratory Alkalosis
Moving to respiratory alkalosis,
This table illustrates about the causes of respiratory alkalosis. These include:
• Decreased oxygen delivery and
• Decreased cardiac output
Based upon the Central Nervous System stimulation the causes include fever, hyperthyroidism and stroke
syndromes.
This table illustrates another set of causes of respiratory alkalosis.
These include:
• Tumors
• Drugs like methylxanthines, nicotine, naloxone, progesterone, and salicylates.
• Gram negative sepsis.
• Hypoxemia and/or hypotension
• Pulmonary diseases like asthma, pulmonary embolism, pulmonary edema and bronchopneumonia.
Summary
All systematic approaches to the diagnosis of acid-base disorders involve critical steps.
For the purposes of respiratory monitoring, a diagnosis of respiratory acidosis or alkalosis should lead to the
search of associated clinical causes and the implementation of appropriate interventions.
Video Transcript
Principles of Gas Exchange
Learning Objectives
• Assess the ventilation and acid-base disturbances and,

• Explain the schematic approach to interpretation of blood gases in detail
Introduction
As a known fact, the Intensive care unit patients are more prone to suffering from lung
diseases more than other types of patients. Therefore, it is very essential to understand
the principles on which gas exchange works. Gas exchange happens when a steady
state is achieved, that is carbon dioxide and oxygen concentrations are more-or-less
the same for several minutes.
The Concepts of Law of Mass Conservation
Before getting into the principles of gas exchange, let’s understand the concepts of
law of mass conservation in brief.
Gas exchange is a process of movement of gas molecules such as carbon- dioxide

and oxygen across the barriers. The law of mass conservation applies during both the
ventilation and the blood flow, where the movement of gas molecules is happening by
convection. Also, this law is applied during gas transfer across the alveolar-capillary
blood gas barrier, where gas transfer occurs by the movement of gas molecules by
diffusion. The movement of gas molecules can be in one of two ways; gas uptake into
the body such as oxygen, or gas elimination from the body such as carbon-dioxide.
Conservation of mass states that all the inhaled oxygen is transferred into the alveolar
capillary blood. This transfer rate is the oxygen uptake.
The equation that governs the O2 inhalation is
VO2 = VA multiplied by FIO2 Minus FAO2
While the next equation explains the O2 transfer into the alveolar blood, that is
VO2 is equal to Q multiplied by CaO2 – CvO2
VO2 is the maximum rate of oxygen consumption. VA is alveolar ventilation, Q is total

pulmonary blood flow, and CaO2 and CvO2 are systemic and pulmonary arterial O2
concentrations, respectively. FIO2 and FAO2 are inspired and alveolar O2
concentrations, respectively.
Adding both equations to each other, here is the equation that rises.
𝑉𝐴
= CaO2 minus CvO2 divided by FIO2 minus FAO2
𝑄
Ventilation/Perfusion Matching and Gas Exchange
Let’s now understand about the Ventilation/Perfusion Matching and Gas Exchange in detail.
𝑉𝐴
● If all lung regions had the same ratio, they would all have the same PaO2 and PaCO2.
𝑄
𝑉𝐴
● In a normal subject breathing sea level air at rest, the ratio of the lung is around 1 and,
𝑄
● It is because total alveolar ventilation and pulmonary blood flow are about the same at 5–6 litres per
min.
Now that we learnt about the gas exchange concepts, the possible physiological causes of hypoxemia
and hypercapnia include:
𝑉𝐴
• inequality
𝑄
• Inspiratory hypoxia
• Hypoventilation
• Diffusion limitation
• Shunt
• Extra-pulmonary factors related to metabolic rate and cardiac output
Causative Factors
Let's discuss each of these causative factors in detail.

𝑉𝐴 𝑉𝐴
inequality is defined as the presence of a range of ratios throughout the lung regions.
𝑄 𝑄
𝑉𝐴
In some regions, the ratio is low, in others it’s normal, and in others it’s high.
𝑄
This impairs overall O2 uptake and CO2 elimination, until compensated by increased O2 extraction,
ventilation, or cardiac output, and causes hypoxemia and hypercapnia.
This can be due to many causes in an ICU patient such as:
• A non-uniformly distributed pathological process throughout the lung-infection,
• Inflammation
• Fluid accumulation vascular obstruction
• Tissue breakdown and,
• Effects of ventilator management and other therapies
Inspiratory hypoxia
Coming to Inspiratory hypoxia,
Its causes are usually very rare in an ICU patient such as reduced inspired partial pressure of oxygen,
ascent to altitude, and plane flight which causes arterial hypoxemia.
Hypoventilation can be due to inadequate lung ventilation causes arterial PO2 to fall and PCO2 to rise.
Diffusion limitation
Diffusion of O2 and CO2 between alveolus and capillary blood is complete within the transit time of a
red cell through the lung capillaries. This helps to maintain alveolar and end capillary PO2 equal. This
applies for PCO2 too.
Shunt
Shunt is defined as blood flowing in the heart in an abnormal direction, that is, from the right side to
the left side of the heart, without any alveolar gas contact. This leads to no O2 uptake or CO2
elimination.
Shunts are the result of either direct communications between the ventricles or atria of the heart, or
blood passing through completely unventilated lung regions. The common causes of shunt include
atelectasis, alveolar filling with fluid or exudate, and pneumothorax.
Few extra pulmonary factors also influence gas exchange. They include
• A decreased cardiac output will require a greater tissue O2 extraction rate to maintain
adequate O2 supply.
• If cardiac output falls, PO2 of the venous blood returning to the lungs also falls.
• Similarly, high cardiac output (in relation to a certain metabolic rate) will result in an elevated
venous PO2.
Conclusion
A good knowledge of principles of gas exchange is essential to avoid tissue hypoxia and, Reduced
oxygen delivery and failure of cellular use of oxygen occur in various circumstances and if not
recognized, it results in organ dysfunction and death.
Video Script
Assessment of Gas Exchange
Learning Objectives
• Assess the methods used in evaluation of gas exchange and
• Explain the variable degrees of invasion, and technical complexity of gases in detail.
Introduction
Assessment of gas exchange function of the respiratory system is a cornerstone in the management of an ICU
patient. This kind of assessment can be either descriptive like how abnormal is gas exchange, mechanistic like
how gas exchange reveal pathophysiological insights or both. There are various methods used in evaluation of
gas exchange. They have variable degrees of invasion, and technical complexity. Usually, the more complex
and invasive, the greater will be the insights gained, and vice versa. The key is to balance the complexities
against the information content needed, to select an approach that is sufficiently useful, yet not overly complex.
Pulse Oximetry
Let us now understand the various methods used to assess exchange of gases during the management of a
patient admitted in the ICU.
• Here is the table that illustrates the Pulse oximetry used in evaluation of gas exchange explaining the
variable degrees of invasion, and technical complexity. The pulse oximetry is a simple and least
invasive technique. Its advantages include an immediate, continuous, and low-cost monitoring,
requiring no specialty training. It is descriptive and the information revealed is Sulphur dioxide or SO2
and heart rate.
Blood Gas Analysis

• This table illustrates the blood gas analysis used in evaluation of gas exchange explaining the variable
degrees of invasion, and technical complexity. The Arterial Blood Gas or ABG technique requires
technicality during sampling and transport. It is more invasive than pulse oximetry and has advantages
of being discrete and analyzes very fast about 1 to 2 minutes to provide data. The data is both
descriptive and mechanistic. It evaluates both acid-base status and gas exchange.
Alveolar-Arterial PO2 Difference
This table describes the Alveolar-Arterial Partial Pressure of Oxygen or A-APO2 difference used in evaluation
of gas exchange explaining the variable degrees of invasion, and technical complexity. A simple technique that
depends on knowing the Partial Pressure or PO2 and solving the alveolar gas equation. It is discrete, not
continuous and reveals mechanistic data.
PaO2/FIO2 Ratio
This table describes Arterial oxygen partial pressure to fractional inspired oxygen or PaO2/FIO2 ratio used in
evaluation of gas exchange explaining the variable degrees of invasion, and technical complexity.
Physiological Shunt
Here is the table that describes about physiological Shunt where the pulmonary shunt fraction or Qs/QT is used
in the evaluation of gas exchange explaining the variable degrees of invasion, and technical complexity. It is
discrete and provides mechanistic data.
Mixed Venous Oxygen Saturation/PO2
This table describes Mixed Venous Oxygen Saturation/PO2 used in evaluation of gas exchange explaining the
variable degrees of invasion, and technical complexity. This technique is invasive, using a catheter placed in the
pulmonary artery. It helps determine whether the cardiac output and oxygen delivery is high enough to meet a
patient’s needs.
Physiological Dead Space

Here’s the table that describes physiological dead space, tidal volume used in evaluation of gas exchange
explaining the variable degrees of invasion, and technical complexity. It is a non-invasive technique and helps
to correct calculation of the dead space and gives information on the ventilatory support of the patient and is
used as a valuable diagnostic tool.
Summary
And to finally conclude the principles underlying alveolar gas exchange have been well-known for the last few
decades. Despite the recent advancements, we still struggle to assess gas exchange in hypoxemic patients.
Henceforth, a thorough knowledge of different methods used in evaluation of gas exchange is important as it
can save one’s life.
Video Script
Respiratory Imaging
Learning Objectives
• Discuss the guidelines given by the American College of Radiology or ACR and
• Explain the advantages of digital imaging
Introduction
Radiographic evaluation of the respiratory system stands to present a golden tool in diagnosing, managing, and
monitoring a wide range of respiratory disorders. However, the most recent related studies continue to prove that
daily imaging of critical patients has absolutely no added benefit over on-demand radiographs. Changing to on-
demand radiographs decreases utilization by approximately 25–35%, and decrease the exposure to potentially
harmful rays, without measurable difference in outcome parameters. These include, ICU or hospital mortality,
length of stay, duration of mechanical ventilation, delay in addressing major unsuspected problems.
The guidelines given by the American College of Radiology or ACR describes the four scenarios where
daily images, using a portable imaging machine, are beneficial. These include:
• New patients should have an admission radiograph on admission or transfer to the ICU
• Stable patients with no change in their clinical status. There is little justification in routine daily
radiographs. Radiographs should be ordered for change in clinical status only
• Insertion or tube or catheter
• Endotracheal tube—between 12–15% tubes are misplaced and mal-positioning, which is rarely
detected clinically. chest x-ray should be obtained immediately after intubation.
• Following intravenous catheter insertion—the overall pneumothorax rate is approximately 10%.
• Chest tube
Digital Imaging, Picture Archiving, and Communication Systems
Recently, digital imaging modalities have been emerging on a wider basis every day to replace the traditional
imaging techniques. Computerized picture archiving systems have replaced the traditional view box, due to
many advantages of the digital system. These advantages include:
• Digital images are available at hand reach, whether at the radiology departments, or at the ICU.
• Manipulation of the digital image contrast, and magnification offer great benefits clinically and
financially by diminishing the number of repeats, saving money and decreasing patient’s exposure to
radiation.
Serial digital portable radiographs and other studies are easier to compare on monitors.
Summary
And to finally conclude Respiratory imaging is one of the mainstay of respiratory medicine. It provides local
information about morphology and function of the lung parenchyma that is unchallenged by other noninvasive
techniques. Henceforth, an appropriate knowledge about the management is important.
Video Script
Blood Pressure Monitoring
Learning Objectives
 Explain invasive and non-invasive blood pressure monitoring

 Discuss accuracy and artefacts in measurements of blood pressure and
 Describe how to interpret of Arterial Pressure Waveform
Introduction
Monitoring of Blood pressure is an essential parameter to manage the hemodynamically unstable patients in
intensive care unit. Plays an important role in anticipating the complications gauge the efficacy of therapeutic
interventions and prevent the risk of disease progression. Effective in monitoring the cardiac functions.
Invasive and Non-Invasive Blood Pressure Monitoring
Let’s understand invasive and non-invasive blood pressure monitoring.
Invasive Blood Pressure monitoring indications include frequent titration of vasoactive drips, aortic surgery,
unstable blood pressure and major surgery involving large fluid shifts.
Non-invasive blood pressure monitoring is widely used to determine the patient’s circulatory status.
Invasive Blood Pressure Monitoring
Invasive or Intra-arterial blood pressure monitoring is a commonly used technique in the intensive care unit.
Intra-arterial blood pressure is monitored by placing a canula into the artery for monitoring the systolic, diastolic
and mean arterial pressure. The blood pressure is monitored by connecting the arterial cannula to a saline-filled
non-compressible tubing with a transducer where the mechanical pressure is converted to kinetic energy. The
kinetic energy is then displayed graphically as numerical pressure and arterial waveform on the monitor.
Complications include arterial thrombosis, distal ischemia, embolism, hemorrhage and damage to the artery.
Non-Invasive Blood Pressure Monitoring

The Non-invasive blood pressure or NIBP monitoring determines the circulatory status. It involves oscillometric
or auscultatory principle to measure systolic, diastolic and arterial mean pressure. The Non-invasive blood
pressure or NIBP monitoring is measured by manual cuff pressure. It is less accurate method of monitoring.
Complications include-ulnar nerve injury, friction blisters or edema of the limb.
Accuracy and Artefacts in Measurements of Blood Pressure (Invasive)
Now let us understand the accuracy and artefacts of invasive blood pressure measurement.
The accuracy of measurements of Blood pressure can be affected by artefacts. The parameters which influence
the arterial pressure measurements include:
 Patency of the line: It is maintained by preparing a flush solution by connecting a soft tube to a bag
filled with 0.9% Sodium chloride plus heparin. The flush solution helps in constant and slow flow of
fluid through the monitoring device and maintaining the patency thereby serving as a medium for
transmission of pressure waves from patient to the transducer.
 Leveling the transducer: It aligns the transducer with the invasive catheter tip and helps in minimizing
the hydrostatic pressure which ensures accurate measurement.
 Zeroing the transducer: It ensures measurement of actual pressures by the transducer providing
accurate data for therapeutic decisions.
Square wave testing: It is used to identify artefacts such as underdamping or overdamping.
The major sources of error which may result in inaccurate blood pressure readings include damping and position
of the transducer.
 Damping: Damping is necessary to avoid misinterpretation of the arterial pressure and inappropriate
medical interventions. Damping includes Overdamping and underdamping.
 Position of the transducer: The arterial pressure waveform displayed is the pressure relative to the
transducer position. If the transducer is placed above the level of the heart, the fluid exerts low arterial
blood pressure. If the transducer is placed below, it may lead to high arterial blood pressure.
Normal, Overdamped and Underdamped Arterial Waveform
The major sources of error which may lead to inaccurate blood pressure readings include:
 Overdamping: Overdamping of arterial waveform occurs when the fast-flush device activation produces
slurred upstroke and downstroke without any oscillations above or below the baseline. Correction is done
by checking for the presence of air bubbles or clot in the catheter.
 Underdamping: Underdamping of arterial pressure occurs when activation of the fast-flush system
produces arterial waveform consists of numerous amplified oscillation above and below the baseline.
Correction is done by removing excess lengths of tubing.
Interpretation of Arterial Pressure Waveform.
Now let us understand interpretation of Arterial Pressure Waveform.
Interpretations assist in the analysis of cardiac function and appropriate medical therapy. The morphology of the
waveform provides information about circulating volume, afterload and so on.
Normal components of the arterial waveform include:
The first one being the Peak systolic pressure which refers to maximum left ventricular systolic pressure.
The second one is Dicrotic notch which refers to closure of the aortic valve refers to dicrotic notch on
waveform.
The third one is Diastolic pressure which refers to the amount of vasoconstriction in the arterial system.
The fourth one is Anacrotic notch which refers to the presystolic rise during the first phase of ventricular
systole.
The fifth one is Aortic valve stenosis which refers to the lower systolic pressure may cause narrow pulse
pressure.
The sixth one is aortic regurgitation which refers to the arterial pressure wave raises rapidly, and the pulse
pressure increases.
The seventh one is pulsus alternans or left ventricular dysfunction which refers to the alternating beats of
larger and smaller pulse pressures are indicative of left ventricular dysfunction.
And the final one is Pulsus paradoxus which is a decrease in the pulse waveform and blood pressure during
inspiration indicates pulsus paradoxus.
Summary
To conclude the effective management of the patients in the intensive care unit can be handled by accurate
measurement and monitoring of cardiac function. Blood pressure monitoring is one of the most commonly
performed procedures in clinical medicine and should be done carefully.
Video Script
Electrocardiographic Monitoring in ICU
Learning Objectives
 Discuss Electrocardiographic monitoring in critically ill patients.

 Explain the normal Electrocardiographic waveform, indications, artefacts and their causes.
Introduction
Electrocardiographic or ECG monitoring is integral to monitor cardiac function in critically ill patients.
Routinely used in hospitals for diagnosing cardiac and non-cardiac diseases. Provides basis of
therapeutic interventions for disorders associated with myocardium in ICU or intensive care unit.
ECG and Cardiac Contraction
Normal Electrocardiographic waveform can be read as:
 P wave indicating initiation of electrical signal from the atria on a normal ECG.
 PR interval indicating atrial depolarization and electrical impulse delay in the atrioventricular
node.
 QRS wave indicating complex represent ventricular depolarization and
 T wave representing Ventricular repolarization.
Indications of ECG
Electrocardiographic monitoring is indicated in patients with acute coronary syndrome, cardiac

arrhythmias, heart failure, electrolyte, drug overdose and so on.
Specific conditions requiring ECG in patients admitted to ICU are broadly classified into three
subgroups.
1. Detection of myocardial ischemia: This affects ventricular depolarization and repolarization.

2. Diagnosing arrhythmia: Early detection of ventricular fibrillation reduces mortality from
myocardial infarction by 20%.
3. Monitoring QT interval: QT interval more than 500 milliseconds is associated with increased
risk of mortality in critically ill patients and in patients with torsades de pointes.
Artefacts and their Causes
Now let’s take a closer look at artefacts and their causes.
Artefacts during Electrocardiographic or ECG monitoring plays an integral role for accurate diagnosis
and appropriate treatment. This table summarizes the types of artefacts and their causes.
Motion artefact: This results from stretching of the skin, which causes a change in the skin voltage in
stratum lucidum. This artefact also includes motion artefact.
Electrostatic artefact: Occurs when a person electrostatically charged moves near the ECG device or
the patient, a voltage is generated as a result of current flow through stratum corneum.
Electromagnetic interference or EMI artefact: Results from electric power lines, cell phones, or any
electrical equipment.
Neuromodulation artefact: Occurs due to implantable neurotransmitters in conditions like seizures,

chronic pain and nausea.
Incorrect lead placement: This obscure P waves which resemble heart block.
Summary
To conclude, electrocardiographic monitoring is integral in critically ill patients for diagnosing diseases
which are of either cardiac or non-cardiac etiologies.
Video Script
Echocardiography in ICU
Learning Objectives
At the end of this topic you will be able to:
• Discuss the importance of Echocardiography in the management of critically ill patients in the intensive
care unit and,
• Identify the various indications and applications of Echocardiography.
Introduction
Echocardiography is one the most common and vital tool for cardiovascular assessment in critically ill patients.
Echocardiography allows to obtain diagnostically accurate images of the heart that can lead to major therapeutic
changes in critically ill patient management.
Indications
Major indications of echocardiography in the ICU setting include:
• Evaluation of severe right ventricle dysfunction
• Hypotension/hemodynamic instability of unknown etiology
• Pericardial effusion/cardiac tamponade
• Respiratory failure/hypoxemia
• Complications post-cardiothoracic surgery and,
• Fluid responsiveness assessment
Assessment of Left Ventricular Function
Let’s now understand the assessment of Left Ventricular Function.
Echocardiography is commonly used for assessing the left ventricular contraction in critically ill patients. This
provides crucial information on etiology and severity of the cardiac disorder.
Assessment of left ventricular function determines the ability of the left ventricle to create adequate stroke volume
and fill at lower diastolic pressures and the most common method recommended by the American Society of
Echocardiography’s Guidelines and Standards Committee to calculate left ventricular ejection fraction (LVEF) is
the discs method or Simpson’s method.
• Patients with impaired systolic function might also have abnormally high diastolic filling pressures.
• Diastolic dysfunction is categorized into three grades. These include:
• Grade I - Mild
• Grade II – Moderate and
• Grade III - Severe
Grade I (Mild) includes Impaired relaxation with normal Left Ventricular filling pressure.
Grade II (Moderate) includes impaired relaxation with moderate elevations of Left Ventricular (LV) filling
pressure and,
Grade III (Severe) includes reversible restrictive Left Ventricular filling pressures.
Evaluation of Right Ventricular Function
Let’s now explore to the evaluation of Right Ventricular Function
The right ventricle aids in venous return and ejects into the low-pressure pulmonary circulation.
Patients in ICU have right ventricular dysfunction secondary to increased right ventricular afterload, which is
associated with elevated pulmonary vascular resistance. Assessment of right ventricular function includes
determination of contractility, pulmonary pressure, size and thickness. Dilatation of the right ventricle is defined
as the ratio between right ventricular and left ventricular end-diastolic diameters.
The ratio in a healthy individual would be less than 0.6 and the ratio between 0.6 to 1 indicates moderate right
ventricular dilatation and greater than or equal to 1 indicates severe right ventricular dilatation.
Assessment of Pericardium
Echocardiography plays an important role in quantifying pericardial effusion and examine conditions related to
right-heart cavities. The four-chamber and subcoastal views using 2D echocardiography is used to assess the
presence of collapse associated with effusion and echocardiography is also used in cases of pericardiocentesis.
Applications of Echocardiography
Echocardiography is recommended in cases of emergency and when there is immediate medical intervention.
Echocardiography is used to assess infectious pericarditis, severe valvular dysfunction, thoracic aorta dissection
and so on.
The table summarizes certain clinical conditions and their echocardiographic signs.
Left ventricular pump failure includes enlarged and spheroid left ventricle and functional mitral regurgitation.
Acute left-sided valvular regurgitation includes rupture of the papillary muscle, signs of severe aortic or mitral
regurgitation and hyperkinetic left ventricle.
Acute right heart failure includes enlarged hypokinetic right ventricle accompanied with pulmonary embolism.
Applications of Echocardiography include:
• Aortic rupture
• Sepsis and
• Prosthetic valve regurgitation
Aortic rupture includes enlargement of the aorta, aortic valve regurgitation and dissection flap in the aorta.
Sepsis includes abscess or destruction of the heart valves and endocarditic vegetation on the valve.
Prosthetic valve regurgitation includes abnormal mobility of prosthesis, severe regurgitation and premature
mitral valve closure.
Summary
Now that we have come towards an end, lets understand that proper assessment of cardiovascular diseases in
critically ill patients in the intensive care unit by echocardiography acts a vital tool in major therapeutic changes
during treatment planning.
Video Script
Central Venous Pressure Monitoring in Intensive Care Unit (ICU)
Learning Objectives
 Analyze the Central Venous Pressure waveform and
 Explain the physiological aspects of Central Venous Pressure waveform
Introduction
The measurement of central venous pressure or CVP is one of the fundamental elements of the standard physical
examination and CVP monitoring involves measurement of vertical height of jugular vein distension above the
sternal angle using fluid-filled manometer or electronic transducer that is connected to a centrally placed catheter.
Physiological Aspects of CVP
Two interacting functions, which include cardiac output and venous return determine the CVP.
Cardiac output is determined by cardiac function and venous return. Typically, the cardiac function is represented
by ‘Starling Curve’, where the cardiac output is given as the function of preload. The right heart preload is
determined by the right atrial pressure before the onset of systole.
Secondly, the determinants of venous return are mean systemic filling pressure (which involves pressure in the small
veins, downstream atrial pressure, and resistance between them). Mean systemic filling pressure can be determined
by volume that distends small veins and the stretchiness of the vein walls. Central venous pressure is useful while
interpreting the therapeutic responses to fluid boluses. In a healthy individual, the central venous pressure is very
low that is not more than 5 millimeters of mercury.
Analysis of CVP Waveform
Let’s now analyze the CVP Waveform.
Interpretation of the CVP waveform helps identify the valvular and atrial pathology and therefore used in ICU.
The CVP provides the information which include:
 The presence of atrial activity in supraventricular tachycardia

 Atrial rhythm
 Mechanical atrial capture in response to pacing and,

 Differential diagnosis of shock
Here is the table that describes about the “a” wave and “v” wave. Conditions such as pulmonary hypertension,
tricuspid stenosis, pulmonary stenosis, Complete heart block and so on demonstrate the “a” wave.
On the other hand, v wave can be seen in the conditions such as Tricuspid regurgitation
Here is the table that describes about the “x” descent, “y” descent and prominent “x” and “y” descent.
In Atrial fibrillation, the “x” descent is absent. On the other hand, in pericardial tamponade and constrictive
pericarditis the “x” descent is exaggerated.
In severe tricuspid regurgitation and constrictive pericarditis, y descent is sharp. However, in right ventricular
infarction, there is prominent “x” and “y” descent waveform.
The displayed diagram describes about Analysis of CVP Waveform. The range of CVP at which the clinically
significant changes occur is from 0 to 10 mmHg.
Therefore, minor errors in the measurement due to differences in leveling may lead to inappropriate clinical
conclusions. It is thus essential to set the zero value at atmospheric pressure and evaluate the deviations of the
measurements using this pressure.
CVP Waveform
The value and the waveform of CVP assist in the diagnosis of various conditions. These include:
 Right ventricular infarction

 Right heart failure
 Cor pulmonale
 Complete heart block
 Pericardial tamponade
 Constrictive pericarditis and,
 Tricuspid regurgitation or stenosis
Summary
The assessment of the CVP is one of the basic elements of a standard physical exam.
Level and duration of central venous pressure should be both monitored for appropriate treatment of the ICU
patients.
Video Transcript
Mixed and Central Venous Saturation Monitoring in ICU Patients
Learning Objectives
• Explain the various factors causing a decrease in mixed venous oxygen saturation and
• Discuss the applications of venous saturation monitoring.
Introduction
Mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2) are the two
hemodynamic parameters to measure venous oxygen saturation in a critical care environment. It
provides information regarding patient's oxygen delivery, oxygen consumption and cardiac output. A
decrease in SvO2 indicates that the cardiac output is not high enough to patients’ oxygen needs.
The factors causing a decrease in mixed venous oxygen saturation are broadly divided into increased
oxygen consumption and decreased oxygen delivery. The signs and symptoms of increased oxygen
consumption include stress, pain, chills/shivering, increased body temperature and so on. Decreased
oxygen delivery includes symptoms like decreased oxygen levels in anemia and hypoxemia.
The other signs and symptoms under decreased oxygen consumption are hypothermia and mechanical
ventilation and increased oxygen delivery include arterial oxygen levels, increased cardiac output,
blood transfusions and so on.
Applications of Venous Saturation Monitoring
Applications of Venous Saturation Monitoring include:
• Central venous oxygen saturation monitoring during surgery
• Post-surgery central venous oxygen saturation monitoring and
• Septic shock
Let’s now understand each of these applications in detail.

• Central Venous Oxygen Saturation Monitoring During Surgery: A decrease during or after
high-risk surgery leads to complications and irreversible organ damage.
• Post-surgery central venous oxygen saturation monitoring: A decrease in the central venous
oxygen saturation increases the risk of morbidity. Patients with low venous oxygen saturation
in ICU are at an increased risk of death.
• Septic Shock is associated with hypotension , hypovolemia , microcirculatory dysfunction and

myocardial depression. The prognosis of central venous oxygen saturation is low in patients
with sepsis.
• Other clinical applications include monitoring in post-coronary artery bypass graft, trauma,
respiratory failure, myocardial infarction.
The algorithm explains the goal oriented therapeutic management of patients with septic shock which
includes administration of fluids, vasopressors, blood transfusions until hematocrit of 30% and further
if the goal is achieved then a maintenance therapy followed by regular evaluation is done.
Conclusion
Resuscitation is considered as a complex process with hemodynamic instability as one of the main
etiological factors leading to tissue hypoxia. Venous oxygen saturation monitoring plays an important
role in improving hemodynamic instability by measuring the two parameters which include mixed
venous oxygen and central venous oxygen saturation.
Pulmonary Artery Catheterization
Video Script
Learning Objectives
By the end of this topic you will be able to:
 Explain the concept of Pulmonary artery catheterization and

 Discuss the indications and contraindications of pulmonary artery catheterization.
Introduction
Hemodynamic monitoring is vital for the management of complications, evaluation of etiological factors,
determination of the severity and evaluation of therapeutic response in critically ill patients. Pulmonary Artery
Catheter was introduced to monitor various circulatory parameters. The pulmonary artery catheterization helps
in therapeutic interventions and assessing hemodynamic abnormalities.
Indiacations of Pulmonary Artery Catheterization
Pulmonary Artery Catheterization, it is indicated in:
 Acute myocardial infarction, such as hypotension, ventricular septal defect, cardiac tamponade, right
ventricular infarction and congestive heart failure
 Septic shock
 Respiratory failure conditions such as acute respiratory distress syndrome and cardiogenic respiratory
failure
 Acute pulmonary embolism
 Assessment of volume status in patients with cirrhosis and renal failure, and
 Surgeries that involve large volume shifts.
Pulmonary Artery Catheterization Sites
Pulmonary artery Catheterization is used in high-risk patients with indicated for elective or emergent non-
cardiac surgery. The common pulmonary artery catheterization sites are:
 The internal jugular vein

 Subclavian vein
 Femoral veins
 External jugular veins, and
 Antecubital veins
Clinical Variables Measured Using Pulmonary Catheterization
Pulmonary artery catheterization is useful in measuring certain clinical variables. They include
 Central venous pressure

 Pulmonary artery pressure
 Pulmonary artery wedge pressure
 Cardiac output
 Mixed venous oxygen saturation
 Stroke volume
 Systemic vascular resistance
 Pulmonary vascular resistance
 Oxygen delivery and consumption
 Stroke index, and
 Cardiac index
Contraindications of Pulmonary Artery Catheterization
Despite its uses, there are certain conditions where pulmonary artery catheterization is contraindicated. It is
contraindicated in conditions where the catheter advancement is interrupted or may lead to complications such
as:
 Tricuspid or pulmonary valve stenosis

 Right atrial or right ventricular mass
 Mechanical tricuspid (or pulmonary) valve prosthesis
 Tetralogy of Fallot
 Tricuspid or pulmonary valve endocarditis
 Neutropenia
 Coagulopathy
 Left bundle branch block
 Digitoxin toxicity
 Arrhythmias
 History of recent implantation, and
 Electrolyte abnormalities
Contraindications of Pulmonary Artery Catheterization
Pulmonary artery catheterization can result in various complications in about 10 to 15% of the patients. Most of
these complications are related to insertion and passage, and catheter use and maintenance. The complications
of venous access may include arterial puncture, damage to the vessels and the heart, hematoma, pneumothorax
and hemothorax.
Conclusion
Pulmonary Artery Catheterization is vital for monitoring various circulatory parameters. It aids in assessing
hemodynamic abnormalities, thus important for the management of complications and is widely indicated in
acute myocardial infarction and septic shock. There have been certain complications reported in about 10 to
15% of the patients like tetralogy of fallot, neutropenia, coagulopathy and arrhythmias. In recent times,
pulmonary artery catheter is used in guiding therapy rather than detecting abnormalities.
Cardiac Output Assessment in ICU patients
Video Script
Learning Objectives
By the end of this lesson, you should be able to:
 Explain the concept of cardiac output and

 Describe the assessment of cardiac output
Introduction
Hemodynamic instability is characterized by altered circulating volume, abnormal cardiac function, and
altered vascular tone. In patients with hemodynamic instability, the imbalance between oxygen demand and
oxygen delivery is the major contributing factor of organ failure. In case severe hemodynamic instability, a
targeted treatment approach is provided by monitoring specific parameters which include cardiac output,
pulmonary arterial occlusion pressure, stroke volume variation, and extravascular water.
Cardiac Output Measurement
Cardiac output measurement is crucial for the monitoring of the cardiac function as it provides the estimate of
total body perfusion oxygen delivery. Cardiac output is the blood volume ejected by the heart per one minute
and described as the product of heart rate and stroke volume. In critically ill patients, the fundamental goal is
to provide adequate oxygen delivery to prevent tissue hypoperfusion. Then, it is followed by optimization of
the cardiac output by administration of fluids.
Cardiac Output Monitoring
Cardiac output can be measured by invasive and noninvasive methods. The invasive method of cardiac output
monitoring is most widely used; however, the ideal system of monitoring cardiac output would be non-invasive
as it is reliable, accurate, and consistent.
Invasive Methods of Cardiac Output monitoring

The commonly used invasive methods of cardiac output monitoring are Fick method and thermodilution method.
This invasive method of cardiac output monitoring is based on the principle suggested by Adolf Fick in 1870.
According to the Fick method, the cardiac output can be calculated from the ratio of oxygen consumption to the
arterial and venous oxygen content difference. The oxygen consumption is measured using special devices,
whereas the arteriovenous difference is calculated by obtaining the samples from arterial blood and mixed
venous blood.
Despite being the accurate method to assess the patients with low cardiac output, Fick method is associated
with complications when used in patients with lung abnormalities.
Coming to thermodilution method, it is based on the dilution principle in which certain amount of indicator is
injected into the bloodstream. Then, the blood flow and blood volume are evaluated by measuring the indicator
concentration downstream at the distal arterial site. The thermodilution method uses a special thermistor which
is inserted into the pulmonary artery through central vein.
Non-invasive Methods of Cardiac Output
Now, let us learn about the non-invasive methods of cardiac output.
The non-invasive methods of cardiac output monitoring include esophageal doppler, transesophageal
echocardiography, lithium dilution cardiac output, pulse contour cardiac output, partial carbon dioxide
rebreathing, and thoracic electrical bioimpedance.
Let’s take a look at the non-invasive methods one by one.
The oesophageal Doppler uses a flexible ultrasound probe to measure blood velocity in the descending thoracic
aorta. This also involves estimation of cross-sectional area of the aorta, which is calculated from patient’s age,
weight and height and allows to obtain hemodynamic parameters such as stroke volume, cardiac output, and
cardiac index. This technique is minimally invasive and is not associated with complications.
The transoesophageal echocardiography helps in obtaining information about cardiac contractility, cardiac
output, filling status, valvular morphology and function. Moreover, it provides the information on the ascending
and descending aortic morphology in the critically ill patient. This technique calculates the cardiac output from
the product of stroke volume and heart rate. For calibrating the stroke volume, flow velocity and the cross-
sectional area should be determined. Numerous studies have been demonstrated that the transoesophageal
echocardiography offers reliable cardiac output measurements. This method is mostly used in ventilated patients
with hemodynamic instability.
Lithium dilution cardiac output method is minimally invasive, which requires venous line and arterial
catheter. During this technique, a dose of 0.3millimoles of isotonic lithium chloride is injected as a bolus via
venous line. Then, the arterial plasma concentration is determined by withdrawing blood across a selective
lithium electrode. The cardiac output is calculated from the lithium dose and area that is subject to the
concentration-tie circulation. According to clinical study reports, this method may provide underestimate of
cardiac output of about 5% when compared to bolus thermodilution technique. Lithium dilution cardiac output
measurement is contraindicated in patients on lithium and atracurium therapy.
Moving to, Pulse contour cardiac output, it involves insertion of an arterial catheter into the femoral axillary,
or brachial artery, which is then connected to pulse contour device. A continuous pulse waveform contour
analysis is obtained, and the stroke volume is calculated. Also, a beat-to-beat analysis of cardiac output is
displayed on the device.
Partial CO2 rebreathing uses carbon dioxide as a marker gas for the estimation of cardiac output with the Fick
method. This technique offers non-invasive measurement of cardiac output by using a new monitor called NICO
which is based on the Fick principle. The carbon dioxide output is measured from minute ventilation and the
carbon dioxide levels.
Coming to, Thoracic electrical bioimpedance provides continuous estimation of cardiac output. The
bioimpedance is the measurement of the amplitude of the changes in the voltage across the thorax region. During
this method, voltage is measured by transmitting small current through the electrodes which are placed on the
neck and lower thorax. The stroke volume is determined by resistivity of the blood, distance between the two
pairs of electrodes, mean thoracic impedance between the electrodes, and ventricular ejection time. Then the
cardiac output is calculated from the stroke volume and heart rate. In addition to determining cardiac output,
this method is also used to measure other parameters such as cardiac index stroke index, end-diastolic index and
systemic vascular resistance.
Thoracic electrical bioimpedance method of cardiac output monitoring is recommended for patients with acute
emergency trauma, pulmonary hypertension, and those who underwent cardiac surgery.
Conclusion
Cardiac output measurement is crucial for the monitoring of the cardiac function as it provides the estimate of
total body perfusion oxygen delivery. Cardiac output can be measured by invasive and non-invasive methods.
However, the invasive method of cardiac output monitoring is most widely used.
Tissue Perfusion Monitoring in ICU Patients
Video Script
Learning Objectives
By the end of this lesson, you should be able to:

 Explain the concept of hypoperfusion and
 Discuss various methods of tissue perfusion monitoring
Introduction
Hypoperfusion is one of the most common conditions that may precede the onset of multivisceral organ
dysfunction syndrome. Therefore, assessing subtle changes is essential to ensure adequate tissue perfusion and
oxygenation. Changes in tissue perfusion at microcirculation level may contribute to increased risk of organ
dysfunction and poor therapeutic outcomes.
Complications of Hypoperfusion
Inadequate oxygen to meet the cellular requirements may lead to:
 Cellular ischemia
 Bacterial translocation
 Worsening of septic shock
 Organ dysfunction
 Multiple organ failure and death
Monitoring Tissue Prefusion
An equilibrium should be maintained between the oxygen consumption and oxygen delivery to ensure normal
metabolic processes and minimize anaerobic metabolism. Adequate reserve of oxygen should be available in
order to cope up with the increased oxygen demands in specific conditions. Tissue perfusion is determined by
cardiac output, distribution of cardiac output and state of microcirculation. Tissue perfusion is monitored through
oxygenation as it is considered as best marker for perfusion.
Methods of Monitoring Tissue Oxygenation

Coming to the methods of monitoring tissue oxygenation,
The traditional method of monitoring tissue oxygenation uses Clark electrode, which involves oxygen reduction
of the silver chloride electrode that generates electric current.
In addition to this, there are other methods to determine tissue oxygenation that include phosphorescence
quenching. This method involves oxygen dependent quenching of phosphorescence in which the fluorescent
emission that is diminished is directly proportional to the amount of oxygen present. Other methods to assess
tissue or global oxygenation involve microelectrodes which are inserted transcutaneously or into intravascular
in-dwelling catheters. There are also specific probes available which are used to measure oxygenation levels of
specific area by placing the probe directly into the subcutaneous tissue, muscle or organs.
Non-Invasive Methods
The non-invasive methods of tissue oxygen saturation involve spectrophotometric measurements based on the
red/infrared light absorption features of oxygenated/deoxygenated hemoglobin. For this, pulse oximetry is the
most widely used tool, which provides the information about the oxygenation and also perfusion. Pulse oximetry
is used in combination with other methods of determining tissue oxygen to identify whether the low tissue
oxygenation is due to inadequate circulation or arterial hypoxemia.
Near-infrared Spectroscopy
Coming to Near-infrared spectroscopy, it is the non-invasive method of monitoring tissue oxygenation. Based
on the measurement of absorption and reflectance of light, NIS calibrates tissue oxygenation by evaluating the
ratio of oxygenated hemoglobin to total hemoglobin at the level of microcirculation. This approach of measuring
tissue oxygenation is widely used as a cerebral oximeter. Near-infrared spectroscopy measures cerebral
oxygenation by transmitting the light into the scalp and skull.
Laser Doppler Technique
The laser Doppler technique for the measurement of tissue perfusion involves analyzing the scattering of light
to determine the amount of blood flow in the area around the probe. Various probes are available which can be
used non-invasively by placing it onto the skin or into the tissue with needle probe.
Screening Tools in the Emergency Department

Let’s explore the screening tools in the emergency department.
Non-invasive techniques such as pulse oximetry and tissue oxygenation are used as routine screening tool for
reduced tissue oxygenation in emergency departments, critical care and peri-operative settings. The alternative
approaches for monitoring the tissue perfusion include magnetic resonance imaging, contrast-enhanced
ultrasonography, and positron emission tomography.
Global Oxygenation
A minimum level of global oxygen delivery and perfusion pressure must be maintained in the critically ill patient.
Global oxygenation can be determined by measuring the net result between oxygen delivery and oxygen
utilization by the tissue. The oxygen saturation measured in the venous blood downstream reflects the net balance
between the global oxygen uptake and delivery. Also, it can be measured intermittently blood gas analysis and
for continuous monitoring, catheterization may be required. The global oxygenation can be influenced by various
factors such as cardiac output, oxygen content, oxygen uptake, oxygen delivery, and organ consumption.
Conclusion
Early detection and correction of tissue hypoxia is essential if progressive organ dysfunction and death are to be
avoided. Tissue perfusion can be explored by monitoring the end result of perfusion, namely tissue oxygenation,
metabolic markers, and tissue blood flow. Tissue oxygenation can be directly monitored locally through invasive
electrodes or non-invasively using light absorbance. The ultimate goal of resuscitation is to restore effective
tissue oxygenation and cellular metabolism.
Lactate Monitoring in ICU Patients
Video Script
Learning Objectives
 Describe the process of lactate metabolism and
 Discuss the various etiological factors and lactate monitoring devices in critically ill patients admitted in
the ICU.
Introduction
Increased lactate levels or hyperlactatemia is one of the common conditions in critically ill patients. Although
it is used to detect tissue hypoxia, the other processes which are not related to tissue hypoxia such as
anaerobic metabolism may also contribute to increased blood lactate levels. Lactate has two optical isomers
that include L-lactate and D-lactate.
In intensive care setting, L-lactate is usually measured as D-lactate production is associated with overgrowth
of the intestinal flora. Increased serum lactate or lactate clearance are the indicators of extent of tissue
hypoxia and adequacy of the resuscitation from septic shock.
Lactate Metabolism
Lactate is the major metabolite in two energy-producing processes that include glycolysis and oxidative
phosphorylation. Glycolysis involves conversion of glucose into pyruvate and Adenosine triphosphate or
ATP. Apart from this, oxidative phosphorylation also involves generation of more energy or ATP. Both
glycolysis and oxidative phosphorylation steadily convert glucose into energy at stable conditions. Pyruvate
is a metabolite which links these two metabolic processes. In case of excess pyruvate production, it
accumulates and diverted to lactate, which is catalyzed by lactate dehydrogenase. Thus, when certain
conditions require large and rapid production of glucose, the lactate acts as buffer accelerating the process of
glycolysis. The etiological factors if increased blood lactate levels include aerobic lactate and anaerobic
lactate production.
In response to decreased cellular oxygen, anaerobic glycolysis increases the production of lactate causing
hyperlactatemia. In critically ill patients, there is an abrupt increase in the lactate levels as the oxygen
demands could not be met by increased oxygen consumption. Microcirculatory processes reduce the
utilization of the oxygen causing hyperlactatemia.
In certain cases, hyperlactatemia may persist and may be due to other causes excluding hypoxia and type B
hyperlactatemia.
The other causes of increased lactate production include:
 Increase in aerobic glycolysis
 Impaired pyruvate dehydrogenase activity
 Decreased clearance of lactate
 Lung disease
 Alkalosis
 Medications (epinephrine, beta-2-agonists, and corticosteroids)
Let’s discuss each of these causes in detail.
Increase in aerobic glycolysis may result in increased pyruvate concentration and hence, elevated serum
lactate levels. The process of glycolysis can be triggered by catecholamine stimulated increased sodium ion
or Na+ and potassium ion or K+ pump activity and also cytokine-mediated glucose uptake.
The pyruvate dehydrogenase activity impairment may occur in septic conditions and in thiamine
deficiency. This may lead to severe hyperlactatemia.
The reduced lactate clearance may occur in patients with liver dysfunction or liver surgery. This may also
occur in patients who underwent cardiac surgery and patients with sepsis.
Lung disease: Lung is one of the major sources of lactate and in cases of pulmonary or extra-pulmonary
disease, certain metabolic adaptations in response to inflammatory mediators may lead to abnormal
production of lactate causing hyperlactatemia.
In case of alkalosis, the involvement of hydrogen ion linked carrier mechanism in the transport of lactate
across the cell membrane increases the lactate efflux.
Certain medications such as epinephrine and beta-2 agonists, corticosteroids, propofol, nucleoside reverse
transcriptase inhibitors, carbon monoxide poisoning, methanol and cyanide may increase the blood lactate
levels.
Other causes of hyperlactatemia are mitochondrial dysfunction, the Warburg effect, Grand mal seizures, and
congenital metabolic diseases.
lactate Monitoring
Let’s now discuss the lactate Monitoring in critically ill patients in the ICU.
The blood lactate levels are measured by point-of-care blood gas analysers, hand-held devices, and other
central laboratory machines. However, the devices used at bedside are reliable when compared to laboratory
measurements. Several clinical studies found satisfactory results that compare arterial levels with capillary,
venous, or central/mixed venous levels. However, the sampling site of the blood may not have an impact on
the lactate levels. During in-vitro analysis, increased glycolysis may lead to elevated blood lactate levels
especially in conditions such as leukocytosis or high hematocrit. To prevent this, a maximum turnaround time
of 15 minutes or storing the sample on ice is recommended. Alternatively, the sampling tubes that contain
fluoride are widely used top prevent in-vitro glycolysis.
Conclusion
Understanding of aerobic and anaerobic mechanisms of lactate production and clearance is crucial for
planning the appropriate therapeutic interventions for hyperlactatemia. The results from two multicentre
clinical trials demonstrated that use of lactate levels for providing goal-directed therapy improved the
therapeutic outcomes. These findings support lactate monitoring in ICU patients and also incorporation of
lactate monitoring into the early resuscitation strategies.
Pulse Contour Analysis
Video Script
Learning Objectives
• Explain how pulse contour analysis is used to determine cardiac output and
• Identify the various devices used for pulse contour analysis.
Introduction
In critically ill patients, monitoring of cardiac output is crucial for the management of abnormal bleeding and
hemodynamic instability. Cardiac output is one of the important parameters to be determined for goal-directed therapy.
Use of a monitoring device accompanied by administration of fluids and vasopressors for achieving therapeutic
endpoints helps in improving the patient outcomes. There are various invasive methods to evaluate cardiac output such
as thermodilution, Fick’s principle, and Doppler. In order to reduce the invasiveness, several new methods have been
introduced in recent years, which include non-invasive or minimally invasive methods. The non-invasive methods for
cardiac output assessment include thoracic electrical impedance, radial applanation tonometry or T-Line, and finger
blood pressure cuffs. The minimally invasive technique for estimation of cardiac output includes pulse contour
analysis, which requires an arterial line to record the input signals. Pulse contour analysis also helps in measuring
stroke volume variation and pulse volume variation.
Let us understand the principle involved in pulse contour analysis.
The pulse contour analysis is based on the principle that the cardiac output is proportional to arterial pressure and
therefore the area under the systolic component of the arterial pressure waveform reflects stroke volume and systemic
vascular resistance. There are several novel devices available commercially for the arterial contour analysis, which
facilitates continuous monitoring of cardiac output and hence, the cardiac function. One of the widely used techniques
used for pulse contour analysis includes Pulse Contour Cardiac Output or Pi-C-C-O.
The various devices used for pulse contour analysis include:
 Vigileo
 Pro-AQT
 LiDCOrapid and
 Most Care
Let’s look at each of these devices in detail.
Vigileo device uses the FloTrac™ transducer which is attached to the radial or femoral arterial catheter. It calibrates
stroke volume and cardiac output by using pulse pressure variations and vascular tone. It is less useful in conditions
characterized by low vascular tone, such as septic shock.
ProAQT: This is connected to ProAQT™ transducer, which is then attached to the femoral arterial catheter. It involves
calibration of the area under the systolic portion of the arterial pressure waveform after the initial autocalibration.
Alternatively, starting cardiac index may be entered manually to obtain stroke volume.
LiDCOrapid involves the calibration of the stroke volume from the arterial pressure waveform. Although this method
is considered less accurate when compared to thermodilution technique, the accuracy can be improved after the first
few hours of monitoring.
Most Care method uses pressure recording analytical method, which is developed by analyzing pulsatile and
continuous flow. The stroke volume can be evaluated from the perturbations of the arterial pressure waveform. Also,
the technique does not require any pressure transducer. The advantage of this type of pulse contour analysis device is
that it does not require any external calculation, and the internal calculation is based on the arterial waveform
morphology.
Prerequisites for Pulse Contour Analysis
Prerequisites for pulse contour analysis include an accurate arterial pressure waveform which is crucial for the
appropriate management of the patients in ICU. A clinical trial estimated that about 30% of arterial pressure waveforms
are over-dampened or under-dampened in ICU. As the pulse contour device does not incorporate automated detection
of incorrect waveforms, the healthcare professional is recommended to visually inspect the pulse contour analysis
device and ensure the correct arterial waveform. To ensure the correct response, a rapid flush test is recommended to
analyze the intrinsic resonance frequency of catheter-transducer.
If the square wave test indicates no visible oscillations or several oscillations may indicate overdamping or
underdamping respectively. Most of the pulse contour devices rely on the identification of the dicrotic notch in the
systolic portion of the arterial pressure waveform. But, in case of over or under-dampened arterial waveforms, the
dicrotic notch may not be detected and hence, leads to inaccurate measurements.
Conclusion
To conclude pulse contour analysis used for determining the cardiac output monitoring is less invasive than pulmonary
artery catheter and also provides volume-based measures of preload which helps in determining volume responsiveness
of the patient.
Cardiovascular Imaging in ICU
Video Script
Learning Objectives
By the end of this topic, you will be able to
 List and Explain the various imaging techniques used in the intensive care unit and
 Discuss the Echocardiographic findings in ICU
Introduction
Cardiovascular imaging in the intensive care unit forms an integral part of the therapeutic management and
includes techniques which are performed bedside as most of the patients in the intensive care unit are highly
dependent.
Cardiovascular Imaging Techniques
The various cardiovascular techniques include Chest X-ray, Computed Tomography Pulmonary Angiogram,
Computed Tomography Coronary Angiogram, Computed Tomography thorax, Left Heart catheterization and
Right Heart Catheterization.
Let’s understand each of these techniques in detail.
Chest X-rays
Chest X-rays are used to identify the pathological conditions in the early stages. The portable anterior-
posterior chest X-ray is widely used in cardiothoracic intensive care units. It mainly helps in identifying
complications associated with indwelling catheters and aetiological factors of hemodynamic instability and
also used to identify cardiomegaly and valve calcification.
Computed Tomography Pulmonary Angiogram
The Computed Tomography Pulmonary Angiogram or CT pulmonary angiography is usually recommended if

there is a suspicion of pulmonary embolism in patients with pulmonary hypertension and hypoxemia. This
technique visualizes the emboli in the pulmonary artery and provides a sensitivity of 85% and specificity of
90%.
Computed Tomography Coronary Angiogram
The Computed Tomography Coronary Angiogram is an imaging test, that obtains an image of arteries that
supply blood to heart. It is a non-invasive tool recommended for patients at low to intermediate risk before
diagnosing by invasive approach. It plays an important role in evaluating the coronary stent and graft patency,
structure of arterial wall and coronary artery dissection. It identifies extra-mural/non-stenotic plaques, which
may be underdiagnosed by traditional angiography.
Computed Tomography Thorax
The Computed Tomography Thorax or CT thorax yields more information than the chest X-ray. This
technique has limitations like patient transportation, exposure to certain doses of radiation and administration
of harmful contrast medium for evaluating the morphology of aortic and pulmonary vasculature. The other
uses of CT thorax are:
• Diagnosis of Occult infection

• Differentiation of effusion
• Empyema and lung abscess
• Guiding the percutaneous drainage
• Assessment of aortic aneurysm
• Diagnosis of pneumonia and
• Interstitial lung disease neoplasm
Left Heart Catheterization
Left Heart Catheterization or LHC is indicated in patients with hemodynamic instability, ventricular
arrhythmias, myocardial infarction, dynamic mitral regurgitation and aortic disruption.
Right Heart Catheterization
Right Heart Catheterization or RHC is considered as a gold standard for hemodynamic monitoring in case of
pulmonary hypertension. It helps in distinguishing between pericardial tamponade and constrictive
pericarditis, confirming the diagnosis of intracardiac shunt and evaluation of pulmonary and bronchial
hemorrhage and so on.
Ultrasound
Ultrasound is the most commonly used method for diagnosing, monitoring and the management of the patients
in the intensive care unit. It has widely been recommended in the recent years due to its ease of use, real-time
diagnostic ability and progressive miniaturization of devices.
Echocardiography
Echocardiography in the intensive care unit ranges from evaluating the patient with cardiac arrest to diagnose
complex pathologies and as per the current resuscitation guidelines, it is recommended to evaluate etiological
factors leading to pericardial tamponade, severe valvular pathology.
Decreased cardiac output is because of valvular disease, intrinsic and extrinsic cardiac disease and the findings
include severe stenotic or regurgitant lesion, hypertrophic obstructive cardiomyopathy and tamponade
pericardial effusion.
Elevated left-sided filling pressure occurs as a result of left ventricle dysfunction and the echo cardiac findings
include short isovolumic relaxation time. Mitral valve disease shows mitral stenosis or regurgitation. Elevated
right-sided filling pressure shows annular dilatation or endocarditis. Sepsis shows findings of ventricular
dilatation systolic/diastolic dysfunction.
Conclusion
To conclude Cardiovascular imaging techniques are performed at the bedside in patients admitted to the
intensive care unit. Most of the techniques show a result of 85% sensitivity and 90% specificity. The several
techniques are used to diagnose the pathological conditions with certain complications reported.
Intracranial pressure monitoring in the ICU
Video Script
Intracranial Pressure Monitoring in the ICU
Learning Objectives
• Explain the significance of monitoring the intracranial pressure in the ICU and
• Discuss the various techniques to monitor the intracranial pressure in the ICU
Introduction
Intracranial pressure or ICP is defined as the pressure within the cranium which is exerted on the brain tissue by
external forces such as blood and cerebrospinal fluid or CSF. Normal range of Intracranial pressure varies
according to age and ranges between 5 millimeters of mercury and 15 millimeters of mercury in adults. Acute
intracranial hypertension or AIH is defined as sustained intracranial pressure greater than 20 millimeters of
mercury for greater than 5 to 10 minutes in a patient that is no being stimulated. Monitoring of intracranial
pressure is essential in neuro-intensive care.
Monro-Kellie Doctrine.
To understand the intracranial pressure monitoring better, let’s begin with the Monro-Kellie Doctrine.
The Monro-Kellie doctrine describes the principle of homeostatic intracerebral volume regulation. The total
volume of brain parenchyma, cerebrospinal fluid and blood is relatively constant. but any increase in one of
these components beyond a compensated range results in intracranial shift from linear to exponential
relationship where small changes result in changes in intracranial pressure. Raised intracranial pressure results
in pressure gradients between compartments and possible herniation of brain structures.
The three types of intracranial pressure include:
 Transtentorial (either lateral or central),
 Tonsillar and,
 Subfalcine
Patients with cerebral herniation present with neurological symptoms, drop in Glasgow Coma Score and
localized signs and symptoms of unilateral motor or sensory findings. Herniation of the uncus of the temporal
lobe results in impaired consciousness dilating the ipsilateral pupil and contralateral hemiplegia. Herniation of
cerebellar through foramen magnum compress the medulla and results in cardiorespiratory impairment,
hypertension, high pulse pressure and Cheynes-Stoke respiration.
Significance
Awareness of intracranial pressure assist in managing patients with space – occupying lesions, pathological
conditions causing an abnormal intracranial pressure and head injuries. Elevation in the intracranial pressure
causes long-term disability like death due to head injuries and other intracranial conditions.
Monitoring intracranial pressure is valuable and is often lifesaving in acute care of Traumatic Brain Injury or
TBI, hydrocephalus, drowning inflammatory, cryptococcal meningitis and postoperative sub-occipital brain
tumors. Patients most often present with symptoms of headache and other symptoms like raised intracranial
pressure.
Indications
The major indication is to calculate the cerebral perfusion pressure by invasive monitoring of intracranial pressure.
Cerebral perfusion pressure is defined as the difference between the intracranial pressure or ICP and mean arterial
pressure or MAP. Cerebral perfusion pressure or CPP is an important surrogate for determining the adequacy of
brain perfusion, and as an endpoint for goal-directed therapy.
Techniques of ICP Monitoring
Now let's explore the techniques of ICP Monitoring
The several techniques available in ICP monitoring differ in accuracy, ease of use and cost and these include:
 Intravascular devices – Fluid couple catheter

 Parenchymal catheter tip pressure transducer devices
 Subdural devices
 Subarachnoid fluid device and,
 Epidural devices
Clinical Features
In non-trauma patients, the clinical features of intra cranial pressure include:

 Headache and vomiting

 Visual disturbance
 Papilloedema and
 Sixth nerve paralysis
Signs of raised ICP are the result of herniation with monitoring done in the initial stages.
Neurological Assessment
A thorough history and clinical examination are performed to determine the etiology and further course of
management. Pupillary abnormalities and abnormalities in ocular movements as determined by spontaneous, dolls
eye or cold caloric testing are important clues to localize brainstem dysfunction.
Examination of fundus is focused on detecting of papilledema. The motor system examination focuses on
identifying posture or flaccidity due to raised intracranial pressure or focal deficits.
General and physical examination findings may give a clue to underlying causes of raised intracranial pressure in
hepatic encephalopathy, rash in viral encephalitis and so on.
Neuroimaging
Let’s take a look at the Neuroimaging.
 The imaging technique of choice for a patient with raised intracranial pressure presenting to emergency room
is Computes tomography or (CT) scan.
 Useful in identifying the features of infection that is meningeal enhancement and brain abscess and tumors.
 Magnetic Resonance Imaging or MRI can detect early stroke, venous thromboses, posterior fossa tumors and
demyelinating lesions missing on CT. If Computed Tomography scan is normal, and the patient has features
of raised ICP, then an MRI with MR venogram is obtained and is stabilized.
Invasive methods of ICP monitoring.
Let’s now understand the invasive methods of ICP monitoring. ICP monitoring determines CSF drainage,
administration of mannitol or sedation. The shape, height and trends of individual and consecutive ICP waveforms
reflect intracranial compliance, cerebrovascular status and cerebral perfusion.
Invasive ICP monitoring can be divided into three groups:
 Transducer-tipped catheters
 Fluid-filled systems and.
 Telemetric methods
Let’s begin with Implantable Transducer Catheter Systems.
 Implantable transducer catheter systems do not use a fluid interface and are in a solid state, microchip or fibre
optic type.
 The transducer is placed directly in the intracranial space.
 Fibre optic transducers measure the pressure based on the pressure-deflection of a flexible diaphragm.
 The pressure dependent light is transmitted through a fibre optic cable towards a displaceable mirror, where
the displacement of the mirror changes the reflection properties of the light that is used to determine
Intracranial pressure.
Here are the various implantable transducer catheter systems used to determine the intracranial pressure.
 The Integra Camino Advanced Monitor is a fibre-optic system that measures brain temperature and
intracranial pressure.
 Strain-gauge systems depend on the change in resistance in response to intracranial pressure, which is
translated into a pressure dependent electronic signal.
 Transducer-tipped catheters measure the intraparenchymal, intraventricular, sub-arachnoid or epidural
intracranial pressure.
 Integrated catheter systems are used for multi-parametric measurements and are a part of advanced
neuromonitoring in intensive care units.
Fluid-Filled Systems
Fluid-filled systems
A transducer is connected to a fluid line communicating with an intracranial compartment used to accurately
measure intracranial pressure (ICP). Catheter is inserted into one of the lateral ventricles, and the external
transducer is held at the same level.
 These are used for administration of therapeutic agents and ventricular drainage of CSF.
 Highly prone to infections and difficult to place.
 Risk of development of oedema is evident however infection and trauma to the brain are low.
 Spiegelberg catheters are the specialized systems that use air as pressure transduction.
Telemetric Systems
Telemetric systems
Intracranial pressure (ICP) monitoring can be achieved by catheter systems used in hospital and clinical settings
under specific conditions to minimize the risks associated with these methods. Patient mobility along with other
risk factors limits the tethered systems for long-term monitoring. Various other methods developed to measure
intracranial pressure (ICP) by an implantable device with data transmission through telemetry is restricted to non-
clinical research.
Non-Invasive Methods of ICP Monitoring
Let’s now explore the non-invasive methods of ICP Monitoring.
Non-Invasive methods are used in chronic conditions as alternative method to invasive methods to overcome the
risk of infection, pain, haemorrhage and discomfort.
The non- Invasive Methods of ICP Monitoring include:
 Impedance Mismatch
 Tympanic Membrane Displacement and
 Transcranial Doppler
The impedance mismatch between carotid arteries and cerebral vessels is used to detect intracranial pressure. The
device consists of a transducer, pressure analyzer and display. This method can be used as a bed-side monitor for
measuring intracranial pressure.
Tympanic membrane displacement
Tympanic membrane displacement or TMD – the cochlear aqueduct connects intracranial fluid system and
labyrinth. Mechanics of the audio-vestibular system can be affected by the changes in the intracranial pressure.
Cerebral Cochlear Fluid Pressure or CCFP is a non-invasive indicator of intracranial pressure (ICP). The
reliability of this technique depends on the tympanic membrane with limitations on its applicability.
Transcranial Doppler(TCD)
Transcranial Doppler or TCD ultrasonography is a non-invasive and a rapid technique which is used to measure
the velocity of blood flow in the cerebral artery. Pulsatility index (PI) is one of the measures in determining the
intracranial pressure using this technique.
Pulsatility index or PI is equal to Peak systolic minus End diastolic velocities by mean flow velocity.
Near Infrared Spectroscopy( NIRS)
Near Infrared Spectroscopy or NIRS technique is used to assess cerebral oxygenation.
Determines the deoxygenated and oxygenated hemoglobin in the brain by deriving the levels of oxygen saturation.
Easily penetrates the skull, hence can be used to determine the intracranial pressure (ICP) by assessing the regional
(frontal) cortical oxygenation (rSO2). Increase in Intracranial Pressure (ICP) is associated with rise in the
Intracranial Pressure (ICP) waveforms.
Optic Nerve Sheath Diameter(ONSD)
The next technique is Optic Nerve Sheath Diameter or ONSD
The sub-arachnoid space present between the dura and white matter of the optic nerve communicates with the
subarachnoid space of the brain. Increase in the intracranial pressure increases the sub-arachnoid space
surrounding the nerve. These changes are determined using transocular ultrasound. However, this technique is an
inadequate replacement for invasive ICP measurement
Fontanometry
The next technique is Fontanometry
Pneumatic applanation fontanometer is a new device used to determine intracranial pressure (ICP) in infants. The
device consists of tambour that is placed on the anterior fontanelle.
External pressure and pulsation amplitude are directly proportional to each other hence, with an increase in
external pressure there is an increase in the pulsation amplitude to the maximum. Accurate Intracranial pressure
estimation can be found in hydrocephalic infants and neonates using fontanometer which is based on strain-gauge
principle.
Pulsed Phase Lock Loop(PPLL) Technique
Pulsed Phase Lock Loop or (PPLL) Technique
An ultrasonic signal of 500kHZ is transmitted through temporal lobe in this system. The transmitted signal on the
inner surface of the contralateral side of the skull is used for transmitting and receiving the signal. A change in
the diameter of the skull causes a change in Pulsed Phase Lock Loop or PPLL output voltage which is in
proportion to cranial diameter pulsations.
Conclusion
The various factors affecting the Intracranial pressure monitoring such as invasiveness, accuracy and cost play an
important role in understanding targeting therapy, pathology and predicting prognosis.
Electroencephalogram Monitoring in the Critically Ill
Video Script
Learning Objectives
• Discuss Electroencephalogram and its applications and
• Outline the fundamentals of Electroencephalogram recording.
Introduction
Electroencephalography or EEG is one of the simplest ways to investigate cerebral activity that can easily record
the changes in both brain structures and function. Advances in technology recordings, including improved
memory storage capability and ability to review recordings through computer has resulted in an expansion of
the use of continuous electroencephalogram. Continuous encephalogram or cEEG recording is done in critically
ill patients.
The Electroencephalogram
The Electroencephalogram records the cerebral activity of the brain and detects potentials that are 1000 times
smaller in amplitude when compared to electrocardiogram.
It is regarding as a composition of various signals, each with is frequency and amplitude. The frequency of these
waves is expressed in Hertz (Hz) and is divided into 5 bands:
 Alpha (8 to 13 Hertz)
 Beta (13 to 35 Hertz)
 Gamma (greater than 35 Hertz),
 Delta (Less than 4 Hertz) and
 Theta (4 to 8 Hertz)
The amplitude varies from 20 to 200 microvolts. The Electroencephalogram or EEG reacts to various intrinsic
and extrinsic factors such as behavioral state like being awake, drowsy and sleepy and so on.
Abnormal changes in the EEG can be divided into three categories:

 Deterioration of normal background patterns

 Appearance of abnormal patterns and
 Disappearance of all activity.
Abnormalities recorded by a specific electrode have their origin in the underlying part of the cortex. Generalized
changes arise from deep structures such as diencephalon or reflects a global pathologic process such as metabolic
encephalopathy.
Fundamentals of Electroencephalogram Recording
Now let’s understand the Fundamentals of Electroencephalogram Recording
Encephalographic measurements employ recording system consisting of:
 Electrodes with conductive media

 Amplifiers with filters
 A/D converter (analogue to digital) and
 Recording device
Electrodes read the signal from the head surface and the amplifiers bring the microvolt signals where they can
be digitalized accurately. There is a change in signals from analogue to digital form by the converter. The
personal computer then stores the information obtained.
The Electroencephalogram recording electrodes and their function are important for acquiring appropriately
high-quality information for interpretation. Acquiring appropriately high-quality information for interpretation.
Different types of electrodes exist with different characteristics which include:
 Reusable disc electrodes made up of gold, silver, stainless steel or tin

 Disposable (gel-less, and pre-gelled types)
 Saline-based electrodes
 Headbands and electrode caps and
 Needle electrodes
Indications
Indications for performing continuous electroencephalogram include Detecting the nonconclusive seizures
or NCSzs and characterizing spells in intensive care unit patients.
Detecting the nonconclusive seizures or NCSzs is also useful in characterizing spells in ICU patients who
may have various paroxysmal or fluctuating signs like sudden posturing or rigidity , tremors, chewing and so
on.
Quantitative electroencephalogram analysis
Quantitative electroencephalogram analysis or qEEG identifies evolving background changes which cannot be
identified when reviewing the raw electroencephalogram data. Non- invasive seizures or NCSzs in critically ill
patients is related to increased mortality compared to those without seizures.
Electroencephalogram in the monitoring of sedation.
Let’s now understand the Electroencephalogram in the monitoring of sedation.
Electrophysiological technique that has an effective source of information on brain function. The availability
and development of various devices are used to monitor electroencephalogram in conscious, anesthetized and
in comatose patients and, in patients during anesthesia, Electroencephalogram is used as an objective means to
assess the depth of anesthesia.
Applications
Now let’s take a look at the Applications of Electroencephalogram.
The greatest advantage of Electroencephalogram is speed. Electroencephalogram provide less spatial resolution
when compared to MRI and PET. Electroencephalogram images are combined with MRI scans for better
allocation in the brain. Electroencephalogram will determine strengths and positions of electrical activity in
several regions of the brain.
Conclusion
Electroencephalography is one of the simplest ways to investigate the activity of the cerebrum and record the
changes in both brain structure and function.
Video Script
Imaging the Central Nervous System In the Critically Ill
Learning Objectives
• Discuss the significance of various imaging techniques on the central nervous system in the critically
ill patients and,
• Explain the various neuroimaging techniques in specific disease conditions.
Introduction
Imaging plays an important role in the diagnosis and monitoring of patients with acute pathology within the
central nervous system. Advent of numerous modalities to monitor physiological and pathological processes in
the brain have remained ineffective when compared to the imaging techniques. Radiological imaging is
considered as the mainstay of routine investigations in neurological practice.
Types of Imaging Techniques
Let’s take a closer look at the various types of imaging techniques.
Computed Tomography: It is a widely available, rapid and accurate imaging technique. No contraindications
in an acute setting. Risk of radiation is likely in young patients and in patients likely to receive numerous
studies. Rapid acquisition and does not require sedation and iodinated contrast is given to visualize blood-
brain barrier breakdown and with angiography to visualize blood vessels.
Magnetic Resonance Imaging uses an intense magnetic field without ionizing radiation. Gadolinium-based,
noniodinated IV contrast agents are used and there are no concerns about their extravasation into brain tissues.
MR angiography or MRA and qualitative MR perfusion-weighted imaging or PWI are done without IV
contrast. Functional MRI or fMRI analyze cerebral blood flow or CBF while performing a task or in the
resting state. Diffusion-weighted imaging or DWI evaluates freedom of water molecule movement.
Neuroimaging in Specific Disease Conditions
Let’s now explore the neuroimaging in specific disease conditions.

Non-contrast head Computed Tomography remains the primary modality for initial evaluation and have
advantages of short examination time, wide availability, fracture detection, paucity of contraindications and
high accuracy. Magnetic Resonance Imaging has limitations of longer examination time, need for sedation in
uncooperative patients and difficulties in monitoring hemodynamically unstable patients.
Infection and Inflammation
Infection and Inflammation
Computed Tomography and Magnetic Resonance Imaging appear normal in encephalitis, but later show areas
of cortical edema or hemorrhage. Herpes simplex virus or HSV show strong predilection for temporal, insular
and cingulate regions in older children and adults but less in neonates.
Acute disseminated encephalomyelitis or ADEM is an immune-mediated, often postinfectious encephalitis

that appears as symmetric demyelination and edema in subcortical white matter.
Stroke
Let’s now take a look at the Stroke.
Stroke is broadly classified as Ischemic and Hemorrhagic. Neuroimaging is required in an emergency setting
to determine the ischemic or hemorrhagic nature of the lesion. Computed Tomography or CT is the imaging
technique of choice to demonstrate acute hemorrhagic lesions. Magnetic Resonance Imaging or MRI is
sensitive in following the progression of hemorrhage.
Subarachnoid Hemorrhage
Magnetic Resonance Imaging (MRI) is the most sensitive technique to detect subarachnoid hemorrhage.
Visualization is done within the first 12 hours. Major drawbacks of Magnetic Resonance Imaging (MRI)
include poor availability, longer scan times and difficulty in transferring and looking after patients.
Anoxic Brain Injuries.
Now let’s understand the anoxic Brain Injuries.
Hypoxic-ischemic injury (HI) to the brain occurs frequently and results in death or long-term neurologic
disability in both adults and children. Treatment is supportive. Imaging techniques like Computed
Tomography or CT, Ultrasonography or US Magnetic Resonance Imaging or MRI are significant in patients
with Hypoxic –ischemic injury or (HI).
Traumatic Lesions
In spine trauma neuroimaging should be performed as an immediate surgical realignment.
In asymptomatic traumatic patients, imaging of the cervical spine is not necessary.
Magnetic Resonance Imaging is used to analyze soft tissues around the spine.
Non -Traumatic Lesions
Magnetic Resonance Imaging is the imaging technique of choice in non-traumatic spinal cord lesions. It is
performed early, as compressive lesions require urgent surgery. Specificity of the appearance of the lesions on
different MRI sequences, potential enhancement, and location will help in differentiating etiologies from
inflammatory to infectious processes, ischemia and vitamin deficiency. The prognosis mainly depends on the
etiology and in case of non-traumatic compression of the spinal cord, to the rapidity of the neurosurgical
management.
Conclusion
Imaging techniques form the mainstay of routine investigations in neurological practice. Initial evaluation of
patients with traumatic brain injuries is best performed with a computed tomography scan. On the other hand,
Magnetic resonance imaging provides more subtle information, as well as prognosis indicators, but is
impractical until the patient’s condition has been stabilized.

M8 - Investigations and Monitoring in The ICU

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Certificate in Critical Care Medicine

 Describe the physiology of the respiratory system and

By the end of this topic, you will be able to:

 Discuss the importance of capnography and

Value of Information Obtained from Capnography

Let’s now understand the value of information obtained from capnography.

 The intra-airway position of the endotracheal tube or ETT followed by intubation.

Phases Visible on the End-Tidal Carbon Dioxide Time Tracing

Now let’s understand each of these four phases in detail.

Phase II includes mixed gas from airways and alveoli

Various Conditions affecting Carbon Dioxide Production

• Hypothermia, and sedation decrease the carbon dioxide production.

Changes in Dead Space Ventilation

The changes include:

 Shock, cardiac arrest, air embolism and pulmonary embolism

• Blocked sensor window

• Blocked sampling tube or

• Delay in achieving a trace

Common Abnormal Patterns

Let’s discuss each of these phases in detail.

• Elevated PETCO2: this might be due to hypoventilation, malignant hyperthermia.

 Assess the ventilation and acid-base disturbances and,

Normal Ranges of Gases

Now let’s understand the assessment of oxygenation in detail.

Assessment of Ventilation and Acid-Base Disturbances

Coming to the Assessment of ventilation and acid-base disturbances:

Let’s now talk about the base excess.

Schematic Approach to Interpretation of Blood Gases

Here is a schematic approach to interpretation of blood gases.

Chronic-Responsive Metabolic Alkalosis

Chloride-Resistant Metabolic Acidosis

Moving to chloride-resistant metabolic acidosis,

Causes of Metabolic Acidosis

Let’s take a closer look at the causes of metabolic acidosis.

 Acute toxin ingestion

Moving to causes of respiratory acidosis,

Causes of Chloride-Responsive Metabolic Alkalosis

Let us now look into the causes of Chloride-Responsive Metabolic Alkalosis

Chloride-Resistant Metabolic Alkalosis

Here are the causes of chloride-resistant metabolic alkalosis.

 Excessive potassium supplementation

Causes of Respiratory Alkalosis

Moving to respiratory alkalosis,

• Decreased oxygen delivery and

• Decreased cardiac output

This table illustrates another set of causes of respiratory alkalosis.

• Drugs like methylxanthines, nicotine, naloxone, progesterone, and salicylates.

• Gram negative sepsis.

• Hypoxemia and/or hypotension

Principles of Gas Exchange

By the end of this topic, you will be able to:

• Assess the ventilation and acid-base disturbances and,

The Concepts of Law of Mass Conservation

Gas exchange is a process of movement of gas molecules such as carbon- dioxide

The equation that governs the O2 inhalation is

VO2 = VA multiplied by FIO2 Minus FAO2

VO2 is the maximum rate of oxygen consumption. VA is alveolar ventilation, Q is total

Ventilation/Perfusion Matching and Gas Exchange

Let's discuss each of these causative factors in detail.

This can be due to many causes in an ICU patient such as:

• A non-uniformly distributed pathological process throughout the lung-infection,

• Fluid accumulation vascular obstruction

• Tissue breakdown and,