Physiologic Monitoring

PHYSIOLOGIC PHYSIOLOGIC MONITORINGMONITORING

CELSO M. FIDEL, MD, FPCS, FPSGSCELSO M. FIDEL, MD, FPCS, FPSGSDiplomate Philippine Board of SurgeryDiplomate Philippine Board of Surgery

Parameters MonitoredParameters Monitored

I.I. Hemodynamic MonitoringHemodynamic MonitoringII.II. RESPIRATORY MonitoringRESPIRATORY Monitoring

III.III. Renal MonitoringRenal Monitoring

IV.IV. Neurologic monitoringNeurologic monitoring

V.V. Metabolic monitoringMetabolic monitoring

VI.VI. temperature monitoringtemperature monitoring

Hemodynamic MonitoringHemodynamic Monitoring

1. Provides information as to the C-P status 1. Provides information as to the C-P status of the patientof the patient

2. Traditional clinical assessment are 2. Traditional clinical assessment are usually unreliableusually unreliable

3. Major changes in the cardiovascular 3. Major changes in the cardiovascular status may not be clinically obviousstatus may not be clinically obvious

4. Invasive techniques must be utilized4. Invasive techniques must be utilized


A. A. Arterial CatheterizationArterial Catheterization1. Indications1. Indications

a. Need for continuous blood a. Need for continuous blood pressure monitoring. pressure monitoring.

b. Need for frequent arterial blood b. Need for frequent arterial blood sampling. sampling.


Conditions that need continuous and accurate BP monitoring:Conditions that need continuous and accurate BP monitoring:

i. Shock statesi. Shock statesii. Hypertensive crisisii. Hypertensive crisis

iii. Surgery in high risk patientsiii. Surgery in high risk patientsiv. Use of potent vasoactive or iv. Use of potent vasoactive or inotropic drugsinotropic drugs

v. Controlled hypotensive anesthesiav. Controlled hypotensive anesthesiavi. Situations that may lead to rapid changes in cardiac function vi. Situations that may lead to rapid changes in cardiac function

Arterial Catheterization


2. contraindications2. contraindications No ABSOLUTE contraindication to arterial No ABSOLUTE contraindication to arterial

catheterizationcatheterization

RELATIVE contraindications are:RELATIVE contraindications are: a. a. Bleeding problems (hemophilia)Bleeding problems (hemophilia)

b. Anticoagulant therapyb. Anticoagulant therapy c. Presence of a vascular prosthesisc. Presence of a vascular prosthesis d. Local infectiond. Local infection



3. Sites of catheterization3. Sites of catheterization

aa. R. Radial arteryadial artery b. Axillary arteryb. Axillary artery

c. Femoral arteryc. Femoral artery d. Dorsalis pedis arteryd. Dorsalis pedis artery

e. Superficial femoral arterye. Superficial femoral artery f. Brachial arteryf. Brachial artery



3. Sites of Catheterization3. Sites of Catheterizationa. radial arterya. radial artery - dual blood supply- dual blood supply - most commonly used site- most commonly used site

- simple canulation- simple canulation - low complication rate- low complication rate

- modified “Allen’s” test – assess ulnar artery- modified “Allen’s” test – assess ulnar artery - Doppler technique, plethysmography, - Doppler technique, plethysmography,

pulse oximetrypulse oximetry


3. Sites of Catheterization3. Sites of Catheterization b. axillary arteryb. axillary artery

- for long term monitoring- for long term monitoring- large size- large size

- close proximity to the aorta- close proximity to the aorta- deep location- deep location

- technical difficulty in insertion- technical difficulty in insertion- located near neurovascular structures- located near neurovascular structures


3. Sites of Catheterization3. Sites of Catheterization

c. femoral arteryc. femoral artery- - large size and superficial locationlarge size and superficial location

- prone to atherosclerosis- prone to atherosclerosis

- difficult to keep clean- difficult to keep clean



d. dorsalis pedisd. dorsalis pedis

e. superficial temporal arterye. superficial temporal artery

- - surgical exposure is requiredsurgical exposure is required

- neurologic complications - neurologic complications observedobserved



f. brachial arteryf. brachial artery

- for short term use only- for short term use only

- median nerve contracture - median nerve contracture (Volkman’s contracture) (Volkman’s contracture)


Arterial CatheterizationArterial Catheterization 4.4. Complications of arterial catheterizationComplications of arterial catheterization

a. failure to cannulatea. failure to cannulate

b. hematomab. hematoma

c. disconnection from monitoring systemc. disconnection from monitoring system


Arterial CatheterizationArterial Catheterization 4.4. Complications of arterial catheterizationComplications of arterial catheterization

d. infectiond. infection- catheters in place for more than 4 days- catheters in place for more than 4 days- surgical insertion- surgical insertion- local inflammation- local inflammation

e. retrograde cerebral embolizatione. retrograde cerebral embolization f. A-V fistula / pseudoaneurysmf. A-V fistula / pseudoaneurysm g. severe pain, distal necrosisg. severe pain, distal necrosis


B. Central Venous CatheterizationB. Central Venous Catheterization1. Indications1. Indications

a. access for fluid therapya. access for fluid therapy

b. access for drug infusionb. access for drug infusion

c. parenteral nutritionc. parenteral nutrition

d. CVP monitoringd. CVP monitoring


B. Central Venous CatheterizationB. Central Venous Catheterization1. Indications1. Indications

e. other indicationse. other indications- aspirate air embolism- aspirate air embolism

- placement of cardiac - placement of cardiac pacemaker / vena cava pacemaker / vena cava

filtersfilters

- hemodialysis access- hemodialysis access

Hemodynamic MonitoringHemodynamic MonitoringB. Central Venous CatheterizationB. Central Venous Catheterization

11. Useful in hypotensive patients. Useful in hypotensive patients2. Tracings for arrythmias2. Tracings for arrythmias3. Gives information about the relationship 3. Gives information about the relationship

between intravascular volume and right between intravascular volume and right ventricular functionventricular function

4. Use of a water manometer for pressure 4. Use of a water manometer for pressure measurementsmeasurements

5. Normal CVP measurement 4-7 mmH2O5. Normal CVP measurement 4-7 mmH2O

Central Venous Pressure MonitoringCentral Venous Pressure Monitoring

In seriously ill patients the In seriously ill patients the vital problemvital problem is is

determination of the determination of the proper amountproper amount of of fluids fluids

and blood requirements necessary to and blood requirements necessary to

MAINTAIN an optimal blood volumeMAINTAIN an optimal blood volume in the: in the:

PreoperativePreoperative

OperativeOperative

PostoperativePostoperative

Hemodynamic Monitoring


Central Venous Pressure Monitoring Central Venous Pressure Monitoring

CVP Monitoring is a reliable procedure CVP Monitoring is a reliable procedure

to evaluate properly and promptly to evaluate properly and promptly

optimal fluidoptimal fluid and and blood requirementblood requirement

in these patientsin these patients..

The procedure removes much of the The procedure removes much of the

guess work in rapid restoration and guess work in rapid restoration and

maintenance of adequate circulation maintenance of adequate circulation

w/o fear of overloading the heartw/o fear of overloading the heart


Central Venous Pressure MonitoringCentral Venous Pressure Monitoring 2. Sites of catheterization2. Sites of catheterization

a. subclavian veina. subclavian vein

- easiest to cannulate- easiest to cannulate

- pneumothorax most common complication- pneumothorax most common complication

- difficult to control bleeding- difficult to control bleeding


Central Venous Pressure MonitoringCentral Venous Pressure Monitoring 2. Sites of catheterization2. Sites of catheterization

b. internal jugular veinb. internal jugular vein - lower risk of pneumothorax- lower risk of pneumothorax - arterial puncture most common complication- arterial puncture most common complication

c. external jugular veinc. external jugular vein

d. basilic veind. basilic vein

Hemodynamic MonitoringHemodynamic Monitoring Central Venous Pressure Monitoring Central Venous Pressure Monitoring ( ( .. CVP measured anywhere in the SVC or IVC CVP measured anywhere in the SVC or IVC

or or their immediate their immediate

tributaries>>>Innominate, tributaries>>>Innominate, and the Common Iliac Veinsand the Common Iliac Veins It is determined by a complex interaction It is determined by a complex interaction

of:of: Blood VolumeBlood Volume Cardiac Pump ActionCardiac Pump Action Vascular ToneVascular Tone Serves as index of circulating blood volume Serves as index of circulating blood volume relative to the Cardiac Pump Actionrelative to the Cardiac Pump Action


Central Venous Pressure Monitoring Central Venous Pressure Monitoring ( (

CVP or the pressure in the Right Atrium & CVP or the pressure in the Right Atrium &

adjacent Caval system will reflect ability of adjacent Caval system will reflect ability of

the Cardiac Pump Action to handle the the Cardiac Pump Action to handle the

returning blood volume at that particular time.returning blood volume at that particular time.

Indications:Indications:

When Massive blood replacement is When Massive blood replacement is

instituted rapidly in rapid exsanguinating instituted rapidly in rapid exsanguinating

type of bleeding.type of bleeding.


Central Venous Pressure Monitoring (Central Venous Pressure Monitoring ( Indications:Indications: In Acute blood volume deficit in cases In Acute blood volume deficit in cases operated for strangulating type of Intestinal operated for strangulating type of Intestinal Obstruction where rapid fluid replacement Obstruction where rapid fluid replacement

is is indicatedindicated

In obscure cases of Shock immediately post-In obscure cases of Shock immediately post- op whether hypovolemic due to internal op whether hypovolemic due to internal bleeding or nonhypovolemic bleeding or nonhypovolemic from from

Myocardial Myocardial Infarction.Infarction.


Central Venous Pressure Monitoring (Central Venous Pressure Monitoring ( Indications:Indications:

In elderly patients with limited cardiac In elderly patients with limited cardiac reserve undergoing difficult, time reserve undergoing difficult, time consuming operations.consuming operations.

In surgical patients with anuria due to In surgical patients with anuria due to possible renal shutdown.possible renal shutdown.


Central Venous Pressure Monitoring Central Venous Pressure Monitoring Basic Facts about CVPBasic Facts about CVP.. Normal CVP is about 4 to 7 cmNormal CVP is about 4 to 7 cm

Low CVP 0-3 circulating blood vol. is Low CVP 0-3 circulating blood vol. is below the normal blood volume the below the normal blood volume the heart can handle.heart can handle.

High CVP 8-20 (more than the heart can High CVP 8-20 (more than the heart can handle)handle)


Central Venous Pressure MonitoringCentral Venous Pressure Monitoring TechniqueTechnique

Cannulation of the Superior Vena Cava Cannulation of the Superior Vena Cava through Basilic or Cephalic Veins.through Basilic or Cephalic Veins.

A polyethelene tube size French 8 and 42 A polyethelene tube size French 8 and 42 inches long is inserted at the Basilic Vein just inches long is inserted at the Basilic Vein just above the elbow and pushed up to 20 inches.above the elbow and pushed up to 20 inches.


Central Venous Pressure MonitoringCentral Venous Pressure Monitoring TechniqueTechnique

Connect an Intravenous administration setConnect an Intravenous administration set to the venous catheter through which IV fluid, to the venous catheter through which IV fluid, may be administered.may be administered.

A Manometer is connected to IV set w/ a A Manometer is connected to IV set w/ a three way stopcock. Zero point should be at three way stopcock. Zero point should be at level of the Atrium or approximately at level of the Atrium or approximately at Mid-axillary lineMid-axillary line


Central Venous Pressure MonitoringCentral Venous Pressure Monitoring

ComplicationsComplications

1. catheter malposition1. catheter malposition

2. dysrythmmias2. dysrythmmias

3. embolization3. embolization

4. vascular injury4. vascular injury

5. cardiac, pleural, mediastinal, 5. cardiac, pleural, mediastinal, neurologic neurologic

injuryinjury

Respiratory MonitoringRespiratory Monitoring

Monitoring ventilation and gas exchangeMonitoring ventilation and gas exchange* Indications* Indications

1. Decision making for the need of 1. Decision making for the need of mechanical ventilation.mechanical ventilation.

2. Assessment of response to therapy.2. Assessment of response to therapy.

3. Optimize ventilatory management.3. Optimize ventilatory management.

4. Decision to wean from ventilator.4. Decision to wean from ventilator.


Monitoring ventilation and gas exchangeMonitoring ventilation and gas exchangeA. Ventilation monitoringA. Ventilation monitoring

1. Tidal volume – volume of air moved in or 1. Tidal volume – volume of air moved in or out out of the lung in of the lung in a single breatha single breath

2. Vital capacity – maximal volume at expiration 2. Vital capacity – maximal volume at expiration after a maximal inspirationafter a maximal inspiration

3. Minute volume – total volume of air leaving 3. Minute volume – total volume of air leaving the lung each minutethe lung each minute

4. Phsiologic dead space – the portion of tidal volume that does not 4. Phsiologic dead space – the portion of tidal volume that does not participate in in gas exchangeparticipate in in gas exchange

a. anatomic dead spacea. anatomic dead spaceb. phsiologic dead spaceb. phsiologic dead space


Monitoring ventilation and gas exchangeMonitoring ventilation and gas exchangeA. Ventilation monitoringA. Ventilation monitoring

4. Phsiologic dead space – the portion of tidal 4. Phsiologic dead space – the portion of tidal

volume that does not participate in in gas volume that does not participate in in gas exchangeexchange

a. anatomic dead spacea. anatomic dead spaceb. phsiologic dead spaceb. phsiologic dead space


Monitoring ventilation and gas exchangeMonitoring ventilation and gas exchange B. Gas MonitoringB. Gas Monitoring

- Reported as directly measured partial - Reported as directly measured partial pressures (PO2 and PCO2)pressures (PO2 and PCO2)

- Use of pulse oximeters for continuous - Use of pulse oximeters for continuous measurementsmeasurements

1. 1. Blood gas analysis Blood gas analysis – information about:– information about:a. efficacy of gas exchangea. efficacy of gas exchangeb. adequacy of alveolar ventilationb. adequacy of alveolar ventilationc. acid – base statusc. acid – base status


Monitoring ventilation and gas exchangeMonitoring ventilation and gas exchange B. Gas MonitoringB. Gas Monitoring 2. Capnography 2. Capnography

- graphic display of CO2 concentration in wave form - graphic display of CO2 concentration in wave form - available systems- available systems

a. infrared analysisa. infrared analysisb. mass spectrometryb. mass spectrometryc. Raman scatteringc. Raman scatteringd. disposable colorimetric devicesd. disposable colorimetric devicese. semi-quantitive measurement on the e. semi-quantitive measurement on the

end-end- tidal CO2 concentrationtidal CO2 concentration


B. Gas MonitoringB. Gas Monitoring33. Pulse oximetry. Pulse oximetry

- reliable, real time reliable, real time estimation of the estimation of the arterial Hgb saturationarterial Hgb saturation

- wide clinical - wide clinical acceptanceacceptance


Monitoring ventilation and gas exchangeMonitoring ventilation and gas exchange B. Gas MonitoringB. Gas Monitoring

4. Gastric Tonometry4. Gastric Tonometry

- relatvely non-invasive monitoring of - relatvely non-invasive monitoring of

adequacy of aerobic metabolism in adequacy of aerobic metabolism in

organs whose superficial mucosal organs whose superficial mucosal

lining is extremely vulnerable to low lining is extremely vulnerable to low flow changes and hypoxemiaflow changes and hypoxemia

Renal MonitoringRenal Monitoring

The kidney is an excellent monitor of The kidney is an excellent monitor of

adequacy of perfusionadequacy of perfusion

Prevention of renal failurePrevention of renal failure

Predict drug clearance and proper dose Predict drug clearance and proper dose

adjustmentadjustment


A. Urine OutputA. Urine Output

- Commonly monitored but may be misleading- Commonly monitored but may be misleading

- Normal urine output - Normal urine output 0.5 ml/kg/hour 0.5 ml/kg/hour

- Correlates with glomerular filtration rate (GFR)- Correlates with glomerular filtration rate (GFR)

- High output may not accurately reflect GFR - High output may not accurately reflect GFR

ex. Diabetes Insipidusex. Diabetes Insipidus

- May be affected by other factors- May be affected by other factors


B. Glomerular Function TestsB. Glomerular Function Tests

1. Blood Urea Nitrogen (BUN)1. Blood Urea Nitrogen (BUN)a. Affected by GFR and urea productiona. Affected by GFR and urea productionb. Increased in TPN, GI bleeding, trauma, b. Increased in TPN, GI bleeding, trauma,

sepsis, steroid usesepsis, steroid usec. Lowered in starvation, liver diseasec. Lowered in starvation, liver diseased. Not a reliable testd. Not a reliable test

Renal MonitoringRenal Monitoring2. Plasma Creatinine2. Plasma Creatinine

a. More accurate than BUNa. More accurate than BUNb. Directly proportional to creatinineb. Directly proportional to creatinine

productionproductionc. Inversely related to GFRc. Inversely related to GFRd. Not affected by protein or nitrogen d. Not affected by protein or nitrogen

production or rate of fluid production or rate of fluid flow through flow through tubulestubules

e. Related to muscle masse. Related to muscle mass


3. Creatinine Clearance3. Creatinine Clearance

a. used if values of plasma creatinine are a. used if values of plasma creatinine are

affected by muscle diseaseaffected by muscle disease

b. serial determination of urine is done b. serial determination of urine is done and and

is currently the most reliable method is currently the most reliable method

of assessing GFRof assessing GFR


C. Tubular Function TestsC. Tubular Function Tests1. The most reliable test to distinguish pre-1. The most reliable test to distinguish pre- renal azotemia from tubular necrosis renal azotemia from tubular necrosis

2. Requires simultaneous collected urine 2. Requires simultaneous collected urine

and blood samplesand blood samples

Neurologic MonitoringNeurologic Monitoring

Early recognition of cerebral Early recognition of cerebral dysfunctiondysfunction

Facilitate prompt intervention Facilitate prompt intervention and treatmentand treatment


A. Intracranial Pressure MonitoringA. Intracranial Pressure Monitoring

1. Cerebral Perfusion Pressure - 1. Cerebral Perfusion Pressure - >70mmHg>70mmHg

2. Glasgow Coma Scale2. Glasgow Coma Scale


B. Electrophysiologic MonitoringB. Electrophysiologic Monitoring

Reflects spontaneous and on-Reflects spontaneous and on- going electrical activity in the going electrical activity in the brainbrain


C. Trans-cranial UltrasoundC. Trans-cranial Ultrasound

Monitors cerebral blood flowMonitors cerebral blood flow

Detects vasospasmDetects vasospasm


D. Jugular Venous OximetryD. Jugular Venous Oximetry

Measures relationship of blood flow Measures relationship of blood flow to O2 consumptionto O2 consumption

Metabolic MonitoringMetabolic Monitoring

A. Caloric DemandsA. Caloric Demands

B. Respiratory Quotient of FoodB. Respiratory Quotient of Food

Temperature MonitoringTemperature Monitoring

A. Rectal A. Rectal

B. Middle EarB. Middle Ear

C. EsophagealC. Esophageal

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Physiologic Monitoring