PGI Roselada, Benjune S.

ARMMC Department of Anesthesiology

DLR: Chapter 26 Commonly Used Monitoring Techniques February 23, 2023

Introduction
● Standards for basic anesthetic monitoring have been established by the American
Society of Anesthesiologists (ASA).
○ For general anesthesia, regional anesthesia, and monitored anesthesia care,
qualified personnel must remain in the operating room to monitor the patient
continuously and to modify anesthesia care based on clinical observations and
the patient's response to dynamic changes following surgery or drug therapy.
○ Standard II focuses attention on continually evaluating the patient’s
oxygenation, ventilation, circulation, and temperature.
■ 1. Use of an inspired oxygen analyzer with a low concentration-limit
alarm during general anesthesia.
■ 2. Quantitative assessment of blood oxygenation during any anesthesia
care.
■ 3. Continuously ensuring the adequacy of ventilation by physical
diagnostic techniques during all anesthesia care. Continual
identification of expired carbon dioxide is performed unless precluded
by the type of patient, procedure, or equipment.
■ 4. Quantitative monitoring of tidal volume and capnography is strongly
encouraged in patients undergoing general anesthesia.
■ 5. When administering regional anesthesia or local anesthesia,
ventilation sufficiency should be assessed by qualitative clinical signs.
During moderate or deep sedation, ventilation shall be evaluated by
continual evaluation of qualitative clinical signs as well as monitoring
for the presence of exhaled carbon dioxide unless precluded by the
type of patient, procedure, or equipment.
■ 6. Ensuring correct placement of an endotracheal tube or laryngeal
mask airway requires clinical assessment and qualitative identification
of carbon dioxide in the expired gas.
■ 7. When using a mechanical ventilator, use of a device that is able to
detect a disconnection of any part of the breathing system.
 ■ 8. The adequacy of circulation should be monitored by the continuous
display of the electrocardiogram, and by determining the arterial blood
pressure and heart rate (HR) at least every 5 minutes. During general
anesthesia, circulatory function is to be continually evaluated by at
least one of the following: palpation of a pulse, auscultation of heart
sounds, monitoring of a tracing of intra-arterial pressure, ultrasound
peripheral pulse monitoring, or pulse plethysmography or oximetry.
■ 9. During all anesthetics, the means for continuously measuring the
patient’s temperature must be available. Every patient receiving
anesthesia shall have temperature monitored when clinically
significant changes in body temperature are intended, anticipated, or
suspected.
● Monitoring of Inspired Oxygen Concentration
○ Principles of Operation
■ Analyzers for oxygen detection include paramagnetic oxygen
analyzers, galvanic oxygen analyzers, and polarographic oxygen
analyzers. Oxygen is a highly reactive chemical, providing many
chemical and physical opportunities to detect its presence.
● The outer shell orbits of non-paired electrons of paramagnetic
gases attract magnetic energy. During electromagnetic
switching, signal changes correlate with oxygen concentration
in a sample line. These instruments detect the change in
pressure in a sample line resulting from oxygen attraction by
switched magnetic fields.
● For operative monitoring, galvanic cell analyzers are required
to measure the current produced when oxygen diffuses across a
membrane and is reduced to molecular oxygen at the anode.
● Oxygen analyzers are commonly used in anesthesia monitoring.
This electrochemical system involves diffusion of oxygen
through a polymeric membrane that is permeable to oxygen.
Among the many oxygen analyzers that use polarographic
oxygen sensors are gas machines, blood gas analyzers, and
transcutaneous oxygen analyzers.
○ Proper Use and Interpretation
 ■ The concentration of oxygen in the anesthetic circuit must be
measured.
■ In anesthesia machines, oxygen sensors are placed on the inspired limb
of the circuit to detect hypoxic gas mixtures and alert the operator.
■ The removable external oxygen sensors seen commonly on anesthesia
machines, such as the Dräger Narkomed and Dräger Fabius (Dräger,
Inc., Telford, PA) are of the galvanic type.
○ Indications
■ According to the ASA Standards for Basic Anesthesia Monitoring,
Standard 2.2.1 states, “During every administration of general
anesthesia using an anesthesia machine, the concentration of oxygen in
the patient's breathing system shall be measured by an oxygen analyzer
with a low oxygen concentration limit alarm in use.”
■ The anesthesiologist monitors the inspired oxygen concentration
carefully during low-flow anesthesia, during which fresh gas flow is
limited to the amount needed to replace the patient's metabolic
demands.
○ Contraindications
■ There are no clinical contraindications to monitoring inspired oxygen
concentration.
○ Common Problems and Limitations
■ There is no guarantee that adequate arterial oxygen concentration will
be achieved with adequate inspiratory oxygen concentration
■ In pediatric anesthesia, it is especially important to monitor FiO2
carefully because of increased awareness of fire hazards in the
operating room. The risk of airway fire is increased during
tonsillectomy and adenoidectomy, two of the most common surgical
procedures in pediatric anesthesia.
● Monitoring of Arterial Oxygenation by Pulse Oximetry
○ Principles of Operation
■ Pulse oximeters measure pulse rate and estimate the oxygen saturation
of hemoglobin (SPO2) on a noninvasive, continuous basis
 ■ A oxyhemoglobin dissociation curve relates the oxygen saturation of
hemoglobin (as a percentage) to the oxygen tension (as a partial
pressure, mmHg). SaO2 and partial pressure of oxygen (PaO2) exhibit
a predictable correlation on the steep part of the curve.
■ Oxyhemoglobin dissociation curves shift to the right when coexisting
medical conditions, such as hypercapnia, acidosis, and hyperthermia,
are present.
■ Pulse oximetry is based on the following premises:
● 1. The color of blood is a function of oxygen saturation.
● 2. The change in color results from the optical properties of
hemoglobin and its interaction with oxygen.
● 3. The ratio of oxyhemoglobin (HbO2) and hemoglobin (Hb)
can be determined by absorption spectrophotometry.
○ Proper Use and Interpretation
■ It is an integral part of anesthesia practice to assess arterial
oxygenation. Hypoxemia can have serious consequences if not
detected and treated promptly.
■ The clinical signs associated with hypoxemia (e.g., tachycardia, altered
mental status, cyanosis) are often masked or difficult to appreciate
during anesthesia.
■ A number of factors can affect the accuracy and reliability of pulse
oximetry during anesthesia care, including dyshemoglobins, dyes
(methylene blue, indocyanine green, and indigo carmine), nail polish,
ambient light, light-emitting diode variability, motion artifacts, and
background noise.
○ Indications
■ Pulse oximetry has been used in all patient age groups to detect and
prevent hypoxemia.
○ Contraindications
■ There are no clinical contraindications to monitoring arterial oxygen
saturation with pulse oximetry.
○ Common Problems and Limitations
 ■ A arterial oxygen monitor cannot guarantee adequate oxygen delivery
or utilization by peripheral tissues and should not be considered a
replacement for arterial blood gas measurements or mixed central
venous oxygen saturation when more definitive information is needed
regarding oxygen supply and utilization.
■ It may take several minutes for pulse oximetry to detect desaturation in
patients who have been breathing supplemental oxygen for several
minutes.
● Monitoring of Expired Gases
○ Principles of Operation
■ The patient’s expired gas is likely to be composed of a mixture of
oxygen (O2), nitrogen (NO2), carbon dioxide (CO2), and anesthetic
gases such as nitrous oxide (N2O) and highly potent halogenated
agents (sevoflurane, isoflurane, or desflurane).
■ Infrared absorption spectrophotometry (IRAS) has now supplanted all
these techniques in clinical practice. Infrared light is absorbed at
specific wavelengths by asymmetric, polyatomic molecules like CO2.
A unique infrared transmission spectrum (like a fingerprint) can be
created for a known gas by passing light through a pure sample of the
gas over a range of infrared frequencies.
■ In an operating room, IRAS devices can detect CO2, N2O, and the
potent inhaled anesthetic agents mixed together in a patient's expired
gas sample.
○ Proper Use and Interpretation
■ An expired gas analysis allows clinicians to monitor simultaneously
the concentrations of CO2 and anesthetic gases inspired and expired.
■ Interpretation of Inspired and Expired Carbon Dioxide Concentrations
● A capnogram is an uninterrupted display of the CO2
concentration sampled at a patient's airway during ventilation.
Capnometry involves measuring the CO2 concentration during
inspiration and expiration.
○ The first phase of expiration (A-B) corresponds to the
anatomic dead space and is normally devoid of carbon
dioxide.
 ○ There is a sharp upstroke in the capnogram at point B,
due to the presence of CO2-containing gas and the
unevenness of expiratory ventilation.
○ As alveolar gas is sampled during phase C-D of the
capnogram, it represents the expiratory plateau.
○ Point D is the highest CO2 value and is called the
end-tidal CO2 (ETCO2). ETCO2 is the best reflection
of the alveolar CO2 (PACO2).
○ As the patient begins to inspire, fresh gas is entrained
and there is a steep downstroke (D–E) back to baseline.
● Using capnography to determine the proper placement of
endotracheal tubes is essential. A stable ETCO2 over three
consecutive breaths indicates that it is not in the esophagus.
● Continuous stable CO2 waveforms confirm alveolar ventilation
but do not necessarily indicate a correctly positioned
endotracheal tube.
● In the absence of a CO2 waveform, a sudden drop in ETCO2 to
near zero implies a potentially life-threatening problem. The
symptoms may include malposition of an endotracheal tube in
the pharynx or esophagus, severe hypotension, massive
pulmonary embolism, cardiac arrest, or disconnection of
sampling lines.
○ Indications
■ A capnogram is the standard of care for monitoring ventilation in
patients receiving general anesthesia. It is also used for monitoring
ventilation during procedures performed while patients are under
moderate or deep sedation.
○ Contraindications
■ Capnography is not contraindicated, provided that the data obtained are
evaluated in light of the patient's clinical circumstances.
○ Common Problems and Limitations
■ The sampling lines or water traps of expired gas analyzers may
become occluded with condensed water vapor during prolonged use.
 ■ For the assessment of arterial carbon dioxide partial pressure,
capnography is not as accurate as blood gas analysis for measuring
ETCO2.
● Invasive Monitoring of Systemic Blood Pressure
○ Principles of Operation
■ By indwelling arterial cannulation, arterial blood pressure can be
monitored continuously and arterial blood can be sampled.
■ The force of the pressure pulse wave is transmitted by fluid-filled
tubing to a pressure transducer, which converts the displacement of a
silicon crystal into voltage changes in intra-arterial blood pressure
monitoring. The arterial pressure trace is generated by amplifying,
filtering, and displaying these electrical signals.
○ Proper Use and Interpretation
■ Multiple arteries can be used for direct measurement of blood pressure,
including the radial, brachial, axillary, femoral, and dorsalis pedis
arteries
■ Due to its accessibility and collateral blood supply, the radial artery
remains the most popular site for cannulation.
■ Three techniques for cannulation are common: direct arterial puncture,
guidewire-assisted cannulation (Seldinger technique), and the
transfixion–withdrawal method.
■ Hematomas, thrombi, and nerve damage have been associated with
trauma-induced cannulation.
○ Indications
■ Generally, arterial blood pressure must be monitored and recorded at
least every five minutes in accordance with basic monitoring1
standards. In most cases, this standard is met by intermittent,
noninvasive blood pressure monitoring. In some cases, however,
continuous monitoring may be necessary due to comorbidities or the
nature of the surgery.
■ A catheter provides continuous blood pressure monitoring, as well as
convenient access to blood for laboratory tests, such as blood gas
analysis to determine respiratory function.Placement of an arterial
 catheter can therefore be indicated by the need for any of these
capabilities:
● Rapid changes in blood pressure or extremes of blood pressure
are anticipated.
● The ability of the patient to tolerate hemodynamic instability is
impaired.
● Compromise of the patient’s respiratory function, oxygenation,
or ventilation is anticipated.
● Metabolic derangements are anticipated.
○ Contraindications
■ The cannulation of the radial artery is an invasive procedure associated
with documented morbidity. Ischemia may occur as a result of
thrombosis, proximal emboli, or prolonged shock after radial artery
cannulation.
○ Common Problems and Limitations
■ Transducer fidelity is maximized when the catheters and tubing are
stiff, the fluid mass is small, the number of stopcocks is limited, and
the connecting tubing is not excessive.
● Intermittent Noninvasive Monitoring of Systemic Blood Pressure
○ Principles of Operation
■ An arterial pulse can be palpated while a more proximal cuff is
deflated in order to estimate systolic blood pressure.
■ By auscultating the Korotkoff sounds, both systolic (SP) and diastolic
(DP) blood pressures can be determined. As a result of mechanical
deformation from the blood pressure cuff, Korotkoff sounds are
generated in an artery. SP is characterized by the first Korotkoff sound.
DP is characterized by a disappearance of the sound or muffled tone.
○ Proper Use and Interpretation
■ In anesthetized patients, automated oscillometry is usually accurate
and versatile.
■ Different strategies of cuff inflation and deflation may be used to
obtain blood pressure measurements.
○ Indications
 ■ ASA Standard 4.2.2 mandates the following: “Every patient receiving
anesthesia shall have arterial blood pressure and HR determined and
evaluated at least every five minutes.”
■ Those patients with medical comorbidities who do not require
continuous monitoring of their blood pressure can usually satisfy this
requirement with an oscillometric noninvasive blood pressure cuff.
○ Contraindications
■ In circumstances where a patient is likely to sustain trauma from
repeated mechanical compression of an encircled limb, noninvasive
blood pressure cuffs are contraindicated.
■ In normal use on a healthy limb, noninvasive blood pressure cuffs can
cause iatrogenic injury. A very prolonged surgical procedure may
result in local skin abrasion or contusion caused by repeated cycling of
the blood pressure cuff; applying a light dressing underneath the cuff
can mitigate these effects.
○ Common Problems and Limitations
■ According to the American Heart Association, the diameter of the
bladder for indirect blood pressure monitoring should be
approximately 40% of the extremity's circumference.
■ Detecting changes in Korotkoff sounds is subjective and susceptible to
error due to deficiencies in sound transmission. Quick deflations
underestimate blood pressure.
■ In conditions of low blood flow or sufficiently stiffened arterial walls,
palpation, auscultation, and oscillometry techniques may not be
reliable due to unreliable detection of pulsations.
● Monitoring of Body Temperature
○ Principles of Operation
■ By metabolizing cells, heat is produced. As an adult, thermoregulation
involves balancing the body's basal metabolic rate, muscular activity,
sympathetic arousal, vascular tone, and hormone release with
exogenous factors that determine whether it is necessary to generate
heat or regulate the transfer of heat to the environment.
■ It is common for anesthesiologists to monitor central core temperatures
and attempt to maintain them at near-normal levels during anesthesia.
 ○ Proper Use and Interpretation
■ Various probes can be used to estimate central core temperatures,
including those placed in the bladder, distal esophagus, ear canal,
trachea, nasopharynx, and rectum.
■ Pulmonary artery blood temperature is also a good estimate of central
core temperature
○ Indications
■ In the course of anesthesia care, it is essential to monitor a patient's
temperature constantly in order to detect malignant hyperthermia or
accidental heat loss.
○ Contraindications
■ It is not contraindicated to monitor temperature in patients with intact
thermoregulation, such as conscious patients or patients receiving light
or moderate sedation.
○ Common Problems and Limitations
■ The monitoring of skin temperature has been recommended to detect
peripheral vasoconstriction, but is insufficient to determine changes in
mean body temperature during surgery.
● Future Trends in Monitoring
○ Three trends in device design appear most likely to lead to further
improvements in our practices: automating monitoring and clinical data
marshal, disseminating our existing devices into a wider hospital setting, and
developing devices with more sophisticated algorithms to obtain clinical data
less invasively.
Source: Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., Ortega,
R. A., Sharar, S. R., & Holt, N. F. (2017). Clinical anesthesia. Wolters Kluwer.
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Patients undergoing surgery or other medical procedures depend on anesthesiologists
to ensure their safety. In addition to administering anesthesia, they also monitor the patient's
vital signs closely throughout the procedure to ensure their safety and stability. It is vital that
anesthesiologists have a thorough understanding of the principles of common monitoring
techniques in order to do this effectively.
By understanding the principles of monitoring techniques, anesthesiologists can
decide which monitoring methods are appropriate for their patients, such as monitoring The
use of electrocardiography (ECG), pulse oximetry, blood pressure monitoring, and
capnography. Understanding how to interpret data from each technique is crucial to detecting
potential complications and responding accordingly, since each technique provides
information about different aspects of a patient's physiological state.
Anesthesiologists can also use monitoring techniques to optimize the dosage and
administration of anesthesia in addition to detecting potential complications. In order to keep
the patient's heart rate and rhythm within safe ranges, anesthesiologists can adjust the dosage
of anesthesia based on monitoring ECG readings. Pulse oximetry allows anesthesiologists to
monitor the patient's oxygen saturation levels, allowing them to adjust breathing or oxygen
supply accordingly.
Overall, the importance of knowing the principles of common monitoring techniques
used by anesthesiologists cannot be overstated. It is essential for ensuring patient safety and
providing high-quality care during surgical procedures.