University of Santo Tomas

Hospital
Department Of
Anesthesiology
Espaa Boulevard, Manila
1008
Anesthesia
Monitoring
Philippines
Latin: Monere means to warn, remind
Pre Residents:
Raina Gaoiran
Britten Norman Santiago

Monitoring
Monitoring equipment is used to
heighten situational awareness of the
anesthesiologist.
Detecting clinical problems more
rapidly
Addressing the problems timely.
However no monitoring equipment
can replace judgment

Standard for Anesthesia monitoring

Standard I
Qualified anesthesia personnel shall be
present in the room throughout the
conduct of all general anesthetics,
regional anesthetics and monitored
anesthesia care.

Standard for Anesthesia monitoring

Sytandard II
During all anesthetics, the patients
oxygenation, ventilation, circulation and
temperature shall be continually
evaluated.

Oxygenation
Inspired gas:
Oxygen Analyzer with Low oxygen
concentration limit alarm.
Mandatory to prevent administration of
hypoxic gas mixture

Oxygenation
Blood Oxygenation
Pulse oximetry: Non-invasive method to
detect hypoxemia.
Pitch pulse tone and low treshold alarm
But it is a poor indicator of adequate
ventilation
Desaturation: late sign of apnea or
respiratory insufficiency

 Pulse Oximetry is based on the

premises:
Color of blood is a function of oxygen
saturation
The change in color results from optical
properties of Hgb in relation to oxygen
The ratio of oxyhemoglobin and
hemoglobin can be determined by
spectrophotometry

spectophotometry
2 wavelengths are used to distinguish
HbO2 from Hb.
The light emiting diodes of the pulse
oximeter emit red and near infrared light.
The pulse oximeter uses plethysmography
to differentiate arterial and venous blood.
absence of a pulsatile waveform during
extreme hypothermia or hypoperfusion can
limit the ability of a pulse oximeter to
calculate the Spo2.

Pulse oximetry
Measures functional saturation

Unlike Laboratory Co-Oximeters use

multiple wavelengths to distinguish
other types of Hb
Co-Oximeter measure fractional
saturation

Factors affecting Pulse

Oximetry

Dyshemoglobins
Dyes
Nail polish
Ambient light
Light emitting diode variability
Motion artifact
Background noise
Electrocautery
Surgical stereotactic positioning systems that
make use of infrared position sensors

Ventilation
Qualitative clinical signs:
Chest excursion
Observation of reservoir breathing bag
Auscultation of breath sounds

Expired CO2
Recommended for procedures involving
moderate to deep sedation

Expired CO2
Capnometry numeric
representation of CO2 concentration
Capnogram continuous
concentrationtime display of the
CO2 concentration sampled at a
patients airway during ventilation.

Capnogram
ETCO2PaCO2 gradient typically is
around 5 mm Hg
End Tidal
CO2
Inspire
fresh gas

Dead
space
Alveolar/expiratory
Plateau

Capnography
Stable ETCO2 for 3 consecutive
breaths:
Tube is not in the esophagus

Stable ETCO2 ensures the presence

of alveolar ventilation
But does not indicate it is placed
properly
It may be either endobronchial (must
auscultate breath ssounds) or placed
proximally in the vocal cord (may easily

Capnography
Slow rate of upstroke
COPD
Acute airway obstruction

Normally shaped but increased ETCO2

Alveolar hypoventilation
Increased CO2 production

Transient increase in ETCO2

Tourniquet release
Bicarbonate administration
Insufflation of CO2 during laparoscopy

Failure of baseline to return to 0

Rebreathing

Sudden drop in ETCO2

May be due to:
Malposition of the ET tube into pharynx/
esophagus
Disruption of airway integrity
Disruption of sampling line
Pulmonary embolism
Severe hypotension
Cardiac arrest

Circulation
Methods for Assessing Circulatory
Function
ECG
Blood pressure and heart rate
determined every 5 minutes
Contiunally evaluated by atleast:
Palpable pulse, Heart sounds, monitoring of a
tracing of intraarterial pressure, ultrasound
peripheral pulse monitoring, or pulse
plethysmography or oximetry.

Blood Pressure Monitoring

Indirect measurement of Arterial BP
Systolic BP
Diastolic BP
Mean Arterial Pressure

Automated Oscillometry

Blood presssure Monitoring

Mechanical errors (auscultatory)
Falsely High BP
Cuff too small (must be 40% of
circumference)
Cuff too loose
Uneven compression of artery
Extremity is below heart level

False low BP
Cuff too large
Rapid deflation
Extremity above heart level

BP Monitoring (Invasive)
Indwelling artrerial cannulation
Continuous BP monitoring
Access for arterial Blood Sampling
Uses fluid filled tubing to transmit a
pressure pulse wave to a pressure
transducer.

BP Monitoring (Invasive)
Physical Limations of fluid filled
pressure transducer systems
Underdamped catheter transducer
systems tend to overestimate SBP by 15
to 30 mmHg
Air bubbles caues overdamping and
Underestimation of BP
MAP is accurately measured either way

BP Monitoring (Invasive)
Arterial cannulation
Radial artery most popular due to its
accesibility and collateral blood
supply

BP Monitoring (Invasive)
Complications
Traumatic: median nerve dysfunction,
hematoma formation and thrombosis
Abnormal radial artery blood flow after
removal of catheter ( normalization after
3 to 7 days)

BP Monitoring (Invasive)
Sudden increases or decreases in blood
pressure may represent a hydrostatic error
sudden decrease in blood pressure may
be caused by a damped tracing from
kinked arterial catheter.
Before initiating therapy based on a
change in blood pressure, the calibration
of the transducer system and the patency
of the arterial cannula should be verified.

SITE

Clinical Points

Radial artery

Preferred cannulation site

Ischemia most likely reflects arterial thrombosis
Aneurysm formation
Arteriovenous fistula formation
Infection Fluid overload in neonates from
continuous flush techniques

Ulnar artery

Complications similar to those of radial artery

Principal source of blood flow to the hand

Brachial artery

Insertion site medial to biceps tendon

Median nerve damage

Axillary artery

Insertion site at junction of pectoralis major and

deltoid muscles

Femoral artery

Easy access in low-flow states

Potential for local and retroperitoneal
hemorrhage
Catheter with increased length preferred

Dorsalis pedis
artery

Collateral circulation via posteriortibial artery

Higher systolic blood pressure

Body temperature
temperature monitoring when
clinically significant changes in body
temperature are intended,
anticipated or suspected