PERIOPERATIVE

MONITORING-
CARDIOVASCULAR SYSTEM

Moderator- Dr Rashmi, associate professor

Presenter- Dr Shreya Shetty.
Cardiovascular system monitoring can be
classified as

Non invasive monitoring

Semi invasive monitoring
Invasive monitoring
Non invasive monitoring
Precordial stethoscope
Pulse rate monitoring
Heart rate monitoring
Blood pressure monitoring
electrocardiogram
echocardiogram
Precordial stethoscope
Stethoscopy provides a simple and reliable
means of listening to heart and breath sounds
continuously throughout an operation .
Pulse rate monitoring

Most monitors report heart rate and pulse rate

separately. The former is measured from the
EKG trace and the latter is determined from a
selectable pulse source.

The pulse oximeter plethysmograph trace is the

most common source for measurement of the
pulse rate, but it may be of poor quality in
patients with severe arterial occlusive disease or
marked peripheral vasoconstriction.
 Heart Rate Monitoring
• The simplest and least invasive form of cardiac monitoring
remains measurement of the heart rate.

• Important guide which tells the influence of anesthetics and

surgical stimuli on the patient's condition.

• The ability to estimate the heart rate quickly with a “finger on

the pulse” is a skill as important as this expression is common.

• EKG is the most common method used in the operating room.

Blood pressure monitoring
 Standards for basic anesthetic monitoring mandate measurement of
arterial blood pressure at least every 5 minutes in all anesthetized
patients.

 The optimal cuff should have a bladder length that is 80% and a
width at least 40% of arm circumference.

 The cuff should be applied snugly, with the bladder centered over
the artery and any residual air squeezed out

 Although too large a cuff will generally work well and produce
little error, use of cuffs that are too small will result in
overestimation of blood pressure.
 manual technique
 To measure both systolic and diastolic arterial pressure, the most
widely used intermittent manual method is the auscultatory technique,
originally described by Korotkoff in 1905.
 The pressure at which the first Korotkoff sound is heard is generally
accepted as systolic pressure (phase I).
 Diastolic pressure is recorded at phase IV or V. However, phase V may
never occur in certain pathophysiologic states such as aortic
regurgitation.
Automated technique
Automated NIBP devices provide audible alarms and can
transfer data to a computerized information system.
The greatest advantage of automated NIBP devices over
manual methods is that they provide frequent, regular
blood pressure measurements and free the operator to
perform other vital clinical duties.
The pressure at which the peak amplitude of arterial
pulsations occurs corresponds closely to directly
measured mean arterial pressure (MAP).
complications
Pain
Petechiae and ecchymosis
Limb oedema
Compartment syndrome
Venous stasis and thrombophlebitis
Peripheral neuropathy
ARTERIAL TONOMETRY
Arterial tonometry measures beat-to-beat arterial blood
pressure by sensing the pressure required to partially flatten a
superficial artery that is supported by a bony structure (eg,
radial artery).
 ELECTROCARDIOGRAM
 The electrocardiogram (EKG) is a representation of
the electrical events of the cardiac cycle.
 Each event has a distinctive waveform, the study of
which can lead to greater insight into a patient’s
cardiac pathophysiology.
 William Einthoven, who used a string galvanogram
for his recordings, first invented the EKG in 1901.
 In the perioperative setting, the EKG serves two
main functions: diagnosis and monitoring.
 During and after surgery, the EKG can detect
changes in rate and rhythm or myocardial ischemia
What types of pathology can we identify and study
from EKGs?
 Arrhythmias
 Myocardial ischemia and infarction
 Pericarditis
 Chamber hypertrophy
 Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)
 Drug toxicity (i.e. digoxin and drugs which prolong the QT
interval)
Waveforms and Intervals

Left to Right - Time

Vertical - measure of voltage
The lines are 1 mm apart, with every fifth line intensified.
The speed of the paper is standardized to 25 mm/sec.
On the horizontal axis, 1 mm represents 0.04 second, and 5mm
represents 0.2 second.
On the vertical axis, 10 mm represents 1 mV.
Precordial Leads
Arrangement of Leads on the EKG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
P-Wave

• Depolarization of atrial muscle

• Low voltage (2-3mm in
amplitude)
• Duration
• Left to Right =<0.11 seconds
Time/duration
• Vertical – measure of voltage (amplitude)
– Expressed in mm
Abnormal P
Waves
• P – Pulmonale
– Tall Peaked
– Right atrial
enlargement
secondary to
pulmonary HTN
(COPD)
• P-Mitrale
– Broad notched
– LA enlargement
secondary to mitral
valve
 P-R Interval
•The PR interval is the
temporal bridge between atrial
and ventricular activation,
during which the AV node, the
bundle of His, the bundle
branches, and the
intraventricular conduction
systems are activated
• Most of the conduction delay
during this segment is due to
slow conduction within the AV
node.
•The normal PR interval is 120
to 200 msec
ST segment and T wave
Repolarization of the ventricles generates the ST
segment and T wave
The junction of the QRS and the ST segment is
called the J point.
The T wave is sometimes followed by a small U
wave, which may be associated with
hypokalemia or hypomagnesemia
 Rule of 300
Take the number of “big boxes” between neighboring QRS
complexes, and divide this into 300. The result will be
approximately equal to the rate
Although fast, this method only works for regular rhythms .

As most EKGs record 10 seconds of rhythm per page, one

can simply count the number of beats present on the EKG
and multiply by 6 to get the number of beats per 60
seconds.

This method works well for irregular rhythms.

What is the heart rate?

33 x 6 = 198 bpm
 Determining the Axis

Predominantly Predominantly Equiphasic

Positive Negative
 The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine if
they are predominantly positive or predominantly negative. The
combination should place the axis into one of the 4 quadrants
below.
Quadrant Approach: Example 1

The Alan E. Lindsay

ECG Learning Center
http://medstat.med.utah
.edu/kw/ecg/

Negative in I, positive in aVF  RAD

The Abnormal Electrocardiogram
Atrial Abnormality
◦ Ectopic atrial activation is often manifested by an abnormal
morphology of the P wave (different from the native P).
◦ Most commonly, negative P waves are seen in the leads where
the P wave is normally upright (leads I, II, aVF, and V4
through V6)
◦ left-sided atrial ectopy is seen more often in association with
LV or left heart valvular abnormalities, whereas right-sided
ectopy is more common in patients with COPD or other causes
of right heart dysfunction
Myocardial ischemia
 The ST segment, representing myocardial
repolarization, is the component of the EKG most
sensitive to acute myocardial ischemia.
 ST elevation, which may be accompanied by tall
positive (hyperacute T waves) , indicates transmural
ischemia .
 Reciprocal ST depression may appear in the
contralateral leads.
 Myocardial infarction
 Transmural infarctions are more likely to culminate in pathologic
Q waves, whereas subendocardial (nontransmural) infarcts are
less likely to produce Q waves
 pathologic Q waves >1 mm in depth
 precordial leads V1 to V3 correspond to the anteroseptal walls of
the left ventricle
 leads V4 to V6 to the lateral LV walls
 leads II, III, and aVF to the inferior LV wall
 the right-sided leads to the right ventricle.
 Posterior wall infarction induces ST elevation or Q waves in
leads placed over the left side and back (V7 to V9), and
reciprocal ST depression or tall R′ waves may develop in leads
V1 to V3
dysrhythmias
dysrhythmias are common during and after
surgery and have numerous causes.
 Postoperative dysrhythmias are most likely to
occur in patients with structural heart disease.
 Sinus bradycardia
 1.Heart rate: Slower than 60 beats/min. In patients maintained on chronic β-
blocker therapy, it is defined as a heart rate of less than 50 beats/min.
 2.Rhythm: Regular
 3. P/QRS: Ratio of 1 : 1.
 4. QRS complex: Normal morphology.
 5.Significance: Heart rates lower than 40 beats/min are poorly tolerated, even
in healthy patients, and should be evaluated on the basis of their effect on
cardiac output.
 Sinus tachycardia
 1. Heart rate: Faster than 100 beats/min in adult patients.
 2. Rhythm: Regular.
 3. P/QRS: Ratio of 1 : 1.
 4. QRS complex: Normal
 5 Significance: Prolonged tachycardia in patients with underlying heart
disease can precipitate MI and congestive heart failure (CHF) as a result of
the increased myocardial work required and decreased myocardial oxygen
supply because of decreased diastolic coronary perfusion time.
Atrial Premature Beats
 An ectopic pacemaker site in the left or right atrium
initiates an atrial premature beat (APB). The shape of
the P wave is different from the usual SA node P wave
and may be inverted.
 no compensatory pause. The absence of a compensatory
pause is an important distinguishing feature between
APBs and VPBs.
 1.Heart rate: Variable, depending on the frequency of
the APBs.
 2. Rhythm: Irregular.
 3. P/QRS: Usually 1 : 1. The P waves have various
shapes and may even be lost in the QRS or T waves.
Occasionally, the P wave is so early that it finds the
ventricle refractory, and a nonconducted beat occurs.
 4. QRS complex: Usually normal unless ventricular
aberration is present.
 5. Significance : They have little clinical significance,
but frequent APBs may lead to other, more serious
supraventricular arrhythmias or may be a sign of
digitalis intoxication.
 Atrial flutter
 Atrialflutter most commonly represents a macro-
reentrant arrhythmia
 Because it is associated with very fast heart rates, it is
generally accompanied by AV block.
 Classic sawtooth flutter waves (F waves) are usually
present
 1.Heartrate: The atrial heart rate is 250 to 350 beats/min with a
ventricular rate of about 150 beats/min
 2. Rhythm: The atrial rhythm is regular. The ventricular rhythm
may be regular if a fixed AV block is present or irregular if a
variable block exists.
 3. P/QRS: Usually there is a 2 : 1 block with an atrial rate of
300 beats/min and a ventricular rate of 150 beats/min, but it
may vary between 2 : 1 and 8 : 1. F waves are best seen in leads
V1 and II
 4.QRS complex: Normal T waves are lost in the f waves.
 5. Significance : Atrial flutter does not always indicate severe
heart disease. It can be seen in patients with CAD, mitral valve
disease, pulmonary embolism, hyperthyroidism, cardiac
trauma, and myocarditis
Atrial fibrillation
 Atrial fibrillation is an excessively rapid and irregular atrial focus
with no P waves appearing on the EKG; instead, fine fibrillatory
activity is seen
 This is the most commonly encountered irregular rhythm.
 It is often described as irregularly irregular and may be associated
with a pulse deficit.
 1.Heart rate: The atrial rate is 350 to 500 beats/min, and the
ventricular rate is 60 to 170 beats/min.
 2. Rhythm: Irregularly irregular.
 3. P:QRS: The P wave is absent and replaced by f waves or
no obvious atrial activity at all.
 4. QRS complex: Normal
 Significance: The loss of atrial “kick” from inefficient
contraction of the atria may reduce ventricular filling and
significantly compromise cardiac output.
 After 24 to 48 hours, atrial fibrillation may be associated
with the development of atrial thrombi, possibly resulting in
pulmonary or systemic embolization.
 Atrial fibrillation is the most common postoperative
arrhythmia and has significant consequences on patient
health.
 Ventricular premature beats
 VPBs result from ectopic pacemaker activity arising below the AV junction.
 The VPB originates in and spreads through the myocardium or ventricular
conducting system, thereby resulting in a wide (>0.12-second), bizarre QRS
complex
 A VPB often blocks the next depolarization from the SA node. The result is a
compensatory pause
 more common in anesthetized patients with preexisting cardiac disease. Other
known etiologic factors include electrolyte and blood gas abnormalities, drug
interactions and trauma to the heart.
 1.Heart rate: Depends on the underlying sinus rate and
frequency of the VPBs.
 2. Rhythm: Irregular.
 3. P/QRS: No P wave with the VPB.
 4. QRS complex: Wide and bizarre, with a width of
more than 0.12 second.
 5. Significance: The new onset of VPBs must be
considered a potentially serious event because in certain
clinical situations, the arrhythmia may progress to VT or
ventricular fibrillation. Such situations include coronary
artery insufficiency, MI, digitalis toxicity with
hypokalemia, and hypoxemia. VPBs are more likely to
precede ventricular fibrillation if they are multiple,
multifocal, or bigeminal
Ventricular tachycardia
 The presence of three or more sequential VPBs
defines VT.
 Diagnostic criteria include the presence of fusion

beats, capture beats, and AV dissociation.

 VT is classified by its duration and morphology. In
duration
◦ nonsustained VT lasts three beats and up to 30 seconds
◦ sustained VT lasts 30 seconds or longer.
 Polymorphic VT with a long QTc is also called
“torsades de pointes.”
 1.Heart rate: 100 to 200 beats/min.
 2. Rhythm: Generally regular, but may be irregular if
the VT is paroxysmal.
 3. P/QRS: Usually there is no fixed relationship
because VT is a form of AV dissociation in which the P
waves can be seen marching through the QRS complex.

 4. QRS complex: Wide, more than 0.12 second in

width, as in VPB.
 5. Significance: Acute onset is life threatening and
requires immediate treatment
Ventricular fibrillation
 Ventricular fibrillation is an irregular rhythm that
results from a rapid discharge of impulses from one
or more ventricular foci
 The ventricular contractions are erratic and are
represented on the EKG by bizarre patterns of
various size and configuration.
 P waves are not seen.
 Important causes of ventricular fibrillation include
myocardial ischemia, hypoxia, hypothermia, electric
shock, electrolyte imbalance
 1. Heart rate: Rapid and grossly disorganized.
 2. Rhythm: Totally irregular.
 3. P/QRS: None seen.
 4. QRS complex: Not present.
 5. Significance: There is no effective cardiac output, and life
must be sustained by artificial means, such as external cardiac
massage that is cardiopulmonary resuscitation must be started.
LBBB
 A basic requirement is a QRS duration of 120 msec or longer.
 There is also a broad, sometimes notched R wave in the left-
sided leads (I, aVL, V5, V6) with deep S waves in the right
precordial leads and absent septal Q waves.
 The QRS duration correlates inversely with the LV ejection
fraction
 RBBB
 The manifestation of RBBB consists of prominent and notched
R waves with rsr′, rsR′, or rSR′ on the right-sided leads and
wide S waves on the left-sided leads
 with QRS prolongation (≥120 msec).
 If the QRS duration is not prolonged, it is termed an
incomplete RBBB.
Transoesophageal echocardiogram
INDICATIONS :

 Intraoperative evaluation of life-threatening

hemodynamic disturbances in which ventricular
function and its determinants are uncertain
 Intraoperative use in valve repair
 Intraoperative use in congenital heart surgery for
most lesions requiring cardiopulmonary bypass
 Intraoperative use in repair of hypertrophic
obstructive cardiomyopathy
 Intraoperative use for endocarditis when preoperative
testing was inadequate or extension of infection to
perivalvular tissue is suspected
 Preoperative use in unstable patients with suspected
thoracic aortic aneurysms, dissection, or disruption who
need to be evaluated quickly
 Intraoperative assessment of aortic valve function
during repair of aortic dissections with possible aortic
valve involvement
 Use in the intensive care unit for unstable patients with
unexplained hemodynamic disturbances, suspected
valve disease, or thromboembolic problems
Absolute contraindications
◦ previous esophagectomy
◦ severe esophageal obstruction
◦ esophageal perforation
◦ ongoing esophageal hemorrhage.
Relative contraindications
◦ esophageal varices, fistula
◦ previous esophageal surgery
◦ history of gastric surgery
◦ mediastinal irradiation
◦ unexplained swallowing difficulties
Invasive monitoring
Central venous pressure monitoring
Pulmonary arterial pressure monitoring
Invasive blood pressure monitoring
central venous catheterization
INDICATIONS

1.Measurement of CVP
2.Rapid administration of fluids and blood
3.Parenteral alimentation
4.Transvenous cardiac pacing
5.Temporary hemodialysis
6.Long term chemotherapy
7.Administration of concentrated vasoactive drugs
and drugs which causes sclerosis of peripheral
veins
8.Frequent blood sampling
9.Frequent therapeutic plasmapheresis.
10.Inadequate peripheral venous access
Waveform Component Phase of Cardiac Cycle Mechanical Event

a wave End diastole Atrial contraction

Isovolumic ventricular
contraction, tricuspid
c wave Early systole
motion toward the right
atrium
Systolic filling of the
v wave Late systole
atrium
Atrial relaxation, systolic
x descent Mid systole
collapse
Early ventricular filling,
y descent Early diastole
diastolic collapse
Condition
Atrial fibrillation
Atrioventricular dissociation
Tricuspid regurgitation
Tricuspid stenosis
Pericardial constriction
Cardiac tamponade
Characteristics
Loss of a wave
Cannon a wave
Tall systolic c-v wave
Loss of x descent
Tall a wave
Attenuation of y descent
Steep x and y descents
M or W configuration
Dominant x descent
Attenuated y descent
Technique of central venous line insertion:

Originally described by Seldinger in 1953

Increasingly popular in recent years
A needle is inserted into a vessel
Angiographic guide is passed through the
needle
Needle is removed
Definitive catheter passed over the wire.
Precautions:
Aseptic insertion technique
Wear a mask
Scrub hands
Wear a sterile gown and gloves
Catheter inserted via cutdown are more prone
to infection than those inserted percutaneously.
Fixation of catheter with sutures
There is a risk of air embolism whenever a
vein is entered and such a risk can be
prevented with head down position, which
increase the venous pressure.
Trendelenburg position – distends the vein
which facilitates cannulation.
Head up position for femoral cannulation.
 Tourniquet for arm vein.
Locator needle
Use of a small 20 G needle to locate the vein
prior to cannulation with a larger needle.
Advantage:
Exploration for the vein with a small needle
will cause less damage to adjacent structures.
Particularly if an artery is unintentionally
punctured.
Leaving the needle in place, once the vein has
been identified, also provides a guide for
venipuncture with a larger needle
 If the blood is pulsatile and bright red – arterial
puncture. If the blood is not pulsatile and dark
red --venous puncture.

Attaching the needle to transducer and

observing for the absence of arterial pressure
wave form.
Pulmonary Arterial Catheterization
Pulmonary Artery Catheter is used to
measure:
pulmonary artery pressure
CVP
Pulmonary artery occlusion pressure (wedge
pressure)
Standard PAC measures
110 cm length, marked at 10 cm intervals
7, 7.5, 8 French circumference ----size
1. Distal port at catheter tip - PAP monitoring
2. Proximal port, 30cm from catheter tip - CVP
monitoring, fluid and drug administration.
3. Third lumen leads to a balloon near catheter tip
4. Fourth contains fine wires leading to a temp.
thermistor, just proximal to balloon.
Normal values
PA systolic pressure = 20-30 mm Hg
PA diastolic pressure = 8-12 mm Hg
About 25/10
technique
 PAC removed from its package and inserted it through a
sterile plastic sheath or sleeve, which covers a length of
PAC residing outside the patient and thereby allows
minor manipulations in PAC position during the
monitoring period while attempting to maintain catheter
sterility
 Care should be taken not to damage the balloon.
Balloon can be inflated with a 1.5 ml volume, packaged
with PAC and inflation syringe should remain attached
to the PAC at all time.
From Right internal jugular vein puncture
site, when the PAC is inserted…
◦ Right atrium 20-25 cm
◦ Right ventricle 30-35 cm
◦ Pulm Artery 40-45 cm
PROXIMAL PORT IN RIGHT ATRIUM
DISTAL PORT
Once the PA catheter is passed for 20 cm, that is
when it is in right atrium, a CVP wave form
noticed on the monitor
Once the PA catheter is passed 30- 35 cm, RV
pressure wave form seen on the monitor.
Once the catheter enters the PA, there will be
“Diastolic step up” a rise in diastolic pressure.
◦ Rapid upstroke
◦ Progressive diastolic runoff
◦ Dicrotic notch
 DISTANCE MARKINGS
Site Distance to PA
Subclavian vein 35-50 cm
Lt Internal Jugular 40-55 cm
Femoral vein 60 cm
 Complications of PAC
During Catheterisation
◦ Arrythmias
◦ Ventricular fibrillation
◦ (Rt) bundle branch block
◦ Complete heart block
◦ Air embolism, due to balloon rupture (with Rt to Lt shunt)
 Misinterpretation of data
 Thromboembolism
 Pulmonary infarction
 Infection, endocarditis
 Endocardial damage
 Cardiac valve injury
 PA rupture & pseudoaneurysm
INVASIVE BLOOD PRESSURE
MONITORING

Blood pressure monitoring is fundamental

in determining the effects of anesthesia on
the CVS.
Arterial blood pressure monitored after
arterial cannulation is known as invasive
blood pressure monitoring.
 Indication for IABP measurement
 When moment to moment BP changes are anticipated---
massive fluid shift.
 Continuous, real time BP monitoring
 Planned pharmacological cardiovascular manipulation,
deliberate hypotension with vasodilators
 Cardiac surgery-- valvular heart disease
 Vascular surgery with major arterial clamping
 Repeated blood sampling for ABG----- One lung ventilation,
Cardio pulmonary by pass
 When NIBP measurement fails – shock, Technically
impossible – burnt extremity, Inaccurate – morbidly obese.
 hypovolemia
Normal arterial waveform
 Abnormal waveforms
Condition Characteristics
Aortic
Pulsus parvus (narrow pulse pressure)
stenosis
Pulsus tardus (delayed upstroke)
Aortic
Bisferiens pulse (double peak)
regurgitation
Wide pulse pressure
Hypertrophic
Spike-and-dome pattern (midsystolic
cardiomyopat
obstruction)
hy
Systolic left
Pulsus alternans (alternating pulse
ventricular
pressure amplitude)
failure
Pulsus paradoxus (exaggerated
Cardiac
decrease in systolic blood pressure
tamponade
during spontaneous inspiration)
Radial artery cannulation
 Assessing the collateral flow before percutaneous radial
artery cannulation – Allen’s test
 Examiner compresses the radial and ulnar arteries.
 Ask the patient to make a tight fist and to open the fist
 Occlusion of ulnar artery released
 Collateral flow is assessed by measuring the time
required for return of normal colour
 Normally palm will have a striking flush within 5
seconds
 5-10 seconds - equivocal test
 > 10 seconds – inadequate collateral circulation
Procedure:

 Wrist dorsiflexed and immobilized

 Prepare the skin with povidone-iodine and alcohol
 Palpate the radial artery proximal to wrist, inject local
anesthetic intradermally and subcutaneously along side
the artery with a 26 G needle (painless and prevents
spasm)
 Small nick at the intended puncture site at 30-45° angle
to the skin along the course of radial artery
 After arterial blood returns, angle is decreased
 Catheter is advanced slightly and then only catheter
threaded into the artery
Commonly radial artery is used for cannulation.
Other arteries:
Ulnar
Femoral (closely resembles aortic pressure, risk
of distal ischaemia less, risk of atherosclerotic
plaque embolisation more)
Posterior tibial
Dorsalis pedis
Axillary, brachial.
Complication
 Distal ischaemia
 Pseudoaneurysm
 Arterial embolization (retrograde, after forceful
flushing)
 Infection
 Peripheral neuropathy
 Hematoma formation
 Necrosis of overlying skin
 Potential blood loss due to disconnection
 Arterial thrombosis (Teflon catheters cause more
thrombosis than catheter made of polypropylene)
 AV fistula
conclusion
 Although cardiovascular monitors receive prime emphasis, the
fundamental basis for circulatory monitoring remains in the
eyes, hands, and ears of the anesthesiologist.
 In many ways, the clinician's senses capture more information
than even the most sophisticated electronic monitors do.
 Combined with knowledge, experience, and sound clinical
judgment, the clinician's senses offer an integrated, panoramic
view of the patient's condition, made even more valuable by an
understanding of the clinical context present.
 Whereas electronic instruments accurately and monotonously
collect huge volumes of quantitative data, the clinician plays a
vital role in patient monitoring by integrating, evaluating, and
interpreting these data.
 References
Miller's Anesthesia 7th edition.
Clinical anesthesia .Paul g Barash.

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