Monitorizarea perioperatorieDana Tomescu SRATI SINAIA 2010

Inceputurile monitorizariiMana pe pulsDin latina: monere = a avertizaDimensiunile pupilei

DefinitieMonitorizarea ne permite urmarirea parametrilor fiziologici prin masuratori rapide, frecvente si reproductibile ceea ce duce la recunoasterea si evaluarea la timp a modificarilor aparute pentru instituirea unei terapii precoce si adecvate de corectare.

ClasificareMonitorizare standard: simplafara riscuri pt screeningcosturi mici creste siguranta actului medical

Monitorizare avansata: management monitoringpt pacientul la risc sau chirurgie la riscindicatii specificecu evaluarea risc/beneficiu trebuie sa duca la imbunatatirea prognosticuluiin general scump

ContentsIntroductionWhat is monitoring?Which, Why and How to monitor?Level of monitoringStandards for basic intraoperative monitoring ( ASA)Systematic monitoringConclusion

Standarde ASA ptr monitorizarea standard intraoperatorie

Standard I Personal calificat pentru anestezie trebuie sa fie prezent in sala de operatie pe tot parcursul desfasurarii actului anestezic (AG, ALR, MAC)Standard II Pe toata durata anesteziei, se evalueaza continuu respiratia (ventilatie, oxigenare), circulatia si temperatura

Monitorizarea standardMonitorizarea EcgPulsoximetriaTA non-invazivaCapnografiaTemperaturaDiureza

Monitorizarea ECGRitmul cardiacTulburari de ritm si de conducere D2 (ischemie, tulburare elctrolitica, stimul nociceptiv etc)Modificari ischemice intraoperatorii: V5 analiza segment ST

Segmentul ST - subdenivelareSemn de ischemie miocardicaIschemia miocardica perioperatorie asociata cu morbiditate si mortalitate postoperatorie crescutaIschemia perioperatorie este silentioasaDepistarea in timp real permite interventie terapeutica prompta

PulsoximetriaMetoda spectrofotometricaDiferentiaza oxi- de deoxihemoglobina prin diferentele in absorbtie la 660nm si 940nmEstimeaza frecventa cardiaca masurand schimbarile ciclice in transmiterea luminii

Infarctul miocardic perioperatorPacientul fr risc: 0,5 % risc pt MIPacient cu risc: 5 % risc pt IM periop chirurgie noncardiacIM periop are mortalitate 10-50%CIFRE, CRITERII Dg i RAPORTARE VARIABILEBoala arterei coronare duce la IM ... Atenie la ANAMNEZ

IM n ultimele 3 luniRat de reinfarctizare 27 %IM cu 3-6 luni nainteRat de reinfarctizare 10 %IM cu mai mult de 6 luni nainteRat de reinfarctizare 5-8 %

Monitorizarea obligatorie standard (EKG; SPO2, TA; diureza, temperatura, Et CO2) Monitorizarea avansat/invaziv: la indicaie Presiune arterial continuPresiune venoas centralPresiune n artera pulmonar blocat/ debit cardiacCateter n artera pulmonarPICCO (monitorizarea minim invaziv a debitului cardiac prin cateter arterial)NICCO (monitorizarea neinvaziv a debitului cardiac prin msurarea CO2 n aerul expirat)Ecografie transesofagian /doppler esofagianSegment ST continuu

3. MonitorizareADECVAT

MonitorizareIschemia trebuie cutat agresiv, tocmai pentru a preveni apariia complicaiilorEdem pulmonarInstabilitate hemodinamicAritmiiInfarct miocardicCum o cutm?ECGTEECateter arter pulmonar

Monitorizarea ischemiei

Monitorizare ECGSensibilitatea metodei crete dac:1. Monitorizarea segment STLeung JM, Voskanian A, Bellows WH, Pastor D: Automated electrocardiograph ST segment trending monitors: accuracy in detecting myocardial ischemia. Anesth Analg 1998; 87:4-10.2. Numrul de derivaiiII/V5 sensibilitate 80%II/V5/V4 sensibilitate 96%Landesberg G, Mosseri M, Wolf Y, Vesselov Y, Weissman C: The probability of detecting perioperative myocardial ischemia in vascular surgery by continuous 12-lead ECG. Anesthesiology 2002; 96:264-70.3. Traseul ECG este imprimat pe hrtiePe ecran sunt recunoscute doar 15-40% din evenimentele ischemice Muller JG, Barash PG: Automated ST-segment monitoring. Int Anes Clin 1993; 31:45-55

Monitorizarea TEETEE: sensibilitate mare + scdere a morbiditiiKallmeyer IJ, Collard CD, Fox JA et al: The safety of transesophageal echocardiography: A case series of 7200 cardiac surgical patients. Anesth Analg 2001; 92: 1126-1130

LimitriSe pierd evenimentele preinducieInterpretarea real-time are acuratee mai sczutDistrage atenia anestezistuluiMiller JP, Lambert S, Shapiro WA et al: The adequacy of basic intraoperative transesophageal echocardiography performed by experienced anesthesiologists. Anesth Analg 2001; 92:1102 1110Valoare pozitiv predictiv pt IM periop de aprox 25%, puin peste valoarea monitorizrii ECG 12 derivaiiHollenberg MJ, London MJ, Leung JM et al: Monitoring myocardial ischemia during noncardiac surgery; A technology assessment of transesophageal echocardiography and 12-lead electrocardiography, JAMA 1992; 268:210-216.

Monitorizare CAPmetod puin sensibil n monitorizarea ischemiei miocardicevan Daele MERM, Sutherland G, Mitchell MM et al: Do changes in pulmonary capillary wedge pressure adequately reflect myocardial ischemia during anesthesia: A correlative perioperative hemodynamic, electrocardiographic and transesophageal echocardiographic study. Circulation 1990; 81: 865-871 nu scade mortalitatea i morbiditarea pacienilor cu risc crescutSandham JD, Hull RD, Brant RF et al: A randomized, controlled trial of the use of pulmonary artery catheters in high-risk surgical patients. N Engl J Med 2003;348:5-14.limitm utilizarea pe criteriul beneficiu-cost

Managementul postoperatorPerioada postop prezint cel mai mare risc de morbiditate cardiac!IMAInsuficien cardiacHipertensiune arterialValvulopatiiAritmiiTulb de conducereOprire cardiacMajoritatea evenimentelor ischemice sunt silenioaseMonitorizarea evenimentelor ischemice trebuie s creasc de la

Pulsoximetria 2

SpO2 si PaO2SpO2 evalueaza cantitatea de oxigen legata de hemoglobinaEchivalenta cu SaO2 masurata in laboratorExceptionala ca metoda non-invazivaPaO2 indica oxigenul dizolvat in plasmaMasurat invaziv prin prelevari de sange arterialEchivalenta SpO2 PaO280-100 mm Hg corespunde cu 95-100% SpO260 mm Hg corespunde cu 90% SpO240 mm Hg corespunde cu 75% SpO2

Limitele pulsoximetrieiCarboxihemoglobinaAnemiaHipovolemiaHipotensiuneaHipotermiaMiscarea, agitatia

CapnometrieMetoda simpla, non-invaziva, fiabilaCapnografia = inregistrarea grafica a variatiilor concentratiei CO2 in timpul ciclului respiratorCapnometria = masurarea concentratiei de CO2 in gazele respiratoriiEvaluare: - FCO2 (%) - pETCO2 (mmHg)

Capnograma normalaval. PEtCO2 = concentratia alveolara medie N = 30-40 mmHgPaCO2 - PEtCO2 = 2-5mmHg morfologie capnogramei

Utilitatea capnogrameiVentilatieajustarea parametrilor ventilatorineuro-chirurgie: PaCo2 - PICchirurgia laparoscopicaHemodinamica: DCMetabolicahipertermie malignatrezire, decurarizare

Intubatia accidentala in esofag detectarea emboliei pulmonare depistarea disfunctionalitatilor la nivelul aparatului de anestezie

Diagnostic capnograficsindrom obstructivreinhalareembolie pulmonara

decurarizare

Monitorizarea functiei neuro-musculareMare variabilitate individuala ca raspuns la actiunea curarelorEvaluarea imprecisa a decurarizarii

Monitorizarea functiei neuro-musculare 2Modele de stimulare

Single Impulse or Twitch (ST)Train of Four (TOF)TetanusDouble Burst Simulation (DBS)Post Tetantic Count (PTC)

Secventa instalarii bloculuidegete, ocular (muschi mici)extremitatitrunchi gatintercostalidiafragmRevenirea se face invers

Monitorizarea profunzimii anestezieiSistemul BISQuantitative EEG Correlations with Brain Glucose Metabolic Rate during Anesthesia in Volunteers Alkire, Anesthesiology 1998

The BIS index was recognized as measuring the hypnotic components of the anesthetic and was relatively insensitive to the analgesic (e.g., opioid) components of an anestheticA, Clinical correlations of the bispectral (BIS) index. Maintaining the BIS index from 45 to 60 during general anesthesia appears to ensure unconsciousness with a hypnotic/opioid anesthetic technique while providing for rapid emergence B, Electroencephalographic (EEG) changes observed with increasing depth of anesthesia. (Adapted from Johansen JW, Sebel PS: Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology 93:1336, 2000.) (Redrawn From Kelley SD: Monitoring Level of Consciousness during Anesthesia and Sedation. Natick, MA, Aspect Medical Systems, 2003.)

Monitorizare invaziva

Presiunea arteriala invazivaCateter intraarterialTransductorMonitor

Presiunea arteriala invaziva 2

Stabilirea punctului zero egalizarea presiunii cu presiunea atmosferica

Presiunea arteriala invaziva 3Can J Cardiol 2000; 86: 121-124

Presiunea arteriala invaziva 4Artere ce pot fi cateterizateRadialaBrahialaAxilara FemoralaPedioasa

Presiunea arteriala invaziva 5Presiunea sistolicaInformatii asupra volumului si vitezei de ejectie a VS, complianta aorteiPresiunea medie cel mai bun indicator de perfuzie tisularaPresiunea diastolicaInformatii asupra rezistentei vasculare

Presiunea arteriala invazivacomplicatiiSangerare, hematomTromboza, embolieInfectie

PVCIndicatii:Evaluarea statusului volemicMasurarea ScVO2Valori Adult 0-8 mmHg (0-11 cmH2O)

PVC 2Cateterizarea unei vene centrale (jugulara interna, subclavie)Acelasi sistem de raportare presionala ca si la artera

PVC - complicatiiPneumotorax incidenta 0.5-6%Punctia arteriala accidentala SangerareInfectie nozocomialaMigrarea cateteruluiErodarea peretelui vascular

Cateterul de arter pulmonar (CAP) Swan-Ganz

CAP - valoriValori masurate:POAPPVCtemperaturaValori derivate:DC/ICRezistente vasculare

Obiectivele monitorizarii cu ajutorul CAPMonitorizarea schimbrilor hemodinamiceGhidarea terapiei in funcie de parametrii hemodinamiciEvaluarea funciei ventriculare drepte si stangiInformaii diagnosticeTabel 2 : Sindroame hemodinamice diagnosticate prin msurarea parametrilor obinui cu CAP

Indicatiile actuale ale monitorizarii cu CAP (1)Pacient instabil hemodinamic care nu rspunde conform ateptrilor la tratamentul convenionalPacient refractar la terapia initialaPacieni care prezint concomitent hipoperfuzie i congestie pulmonarPacieni la care statusul volemic i presiunile de umplere sunt neclarePacieni cu hipotensiune arterial semnificativ i funcie renal in agravare1.Mebazaa A, Gheoghiade M, Pia IL et al. Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes. Crit Care Med 2008;S129

CAP cu DC si SvO2 continuuform modificat a CAP permite evaluarea continu a DC pe baza metodei termodiluiei precum si evaluarea continu a SvO2 permite depistarea mai precoce a unei modificri hemodinamice ghidarea terapiei in funcie de modificarile SvO2. (1,2) 1.Burchell SA, Yu M, Takiguchi SA, Ohta RM, Myers SA, Evaluation of a cardiac output and mixed venous oxygen saturation catheter in critically ill surgical patients, Critical Care Medicine, 25, 3, 1997: 388-3982.Weil, MH, The assault on the Swan-Ganz catheter. Chest 113,1379-1386

VariabileAbreviereModalitate de msurare sau formul de calculValori normaleFrecventa cardiacaHRMasuratoare directa72 88 bpmTensiune arteriala sistemica medieMAPMasuratoare directa81 102 mm HgPresiune venoasa centralaCVPMasuratoare directa1 9 mm HgTensiune arteriala pulmonara medieMPAPMasuratoare directa11 15 mm HgPresiune pulmonara blocataPAOPMasuratoare directa0 12 mm HgIndex cardiacCIMasuratoare directa2.8 3.6 l/min/mVolum bataie indexatSISI = CI/HR30 50 ml/mLucru mecanic al ventriculului stang indexatLVSWILVSWI = SI x MAP x 0.014444 - 68 gxm/mLucru mecanic al ventriculului drept indexatRVSWIRVSWI = SI x MPAP x 0.01444 8 gxm/mRezistenta vasculara sistemica indexataSVRISVRI = 79.92 x ( MAP CVP )/CI1760 2600 dyne/second/cm-5/ mRezistenta pulmonara indexataPVRIPVRI = 79.92 x ( MPAP PAOP )/CI45 225 dyne/second/cm-5/ mHemoglobinaHgbMasuratoare directa12 16 g/dlPh arterialphMasuratoare directa7.36 7.44Presiune arteriala a oxigenuluiPaO2Masuratoare directa10.7 13.3 kPaPresiunea oxigenului in sangele venos amestecatPvO2Masuratoare directa4.4 7.1 kPaSaturatia arteriala a oxigenuluiSaO2Masuratoare directa95 99 %Saturatia oxigenului in sangele venos amestecatSvO2Masuratoare directa75 79 %Continutul arterial in oxigenCaO2CaO2 = ( Hgb x SaO2) + ( PaO2 x 0.0032 )15 20 ml/dlContinutul sangelui venos amestecat in oxigenCvO2CvO2 = ( Hgb x SvO2 ) + ( PvO2 x 0.0032 )10 15 ml/dlDiferenta arterio-venoasa a continutului in oxigenC(a-v)O2C(a-v)O2 = CaO2 CvO24 5.5 ml/dlAportul de oxigen indexatDO2lDO2l = CaO2 x CI x 10520 720 ml/min/ mConsumul de oxigen indexatVO2lVO2l = C(a-v)O2 x CI x 10100 180 ml/min/ m

De ce monitorizare DC?Presarcina, contractilitatea, postsarcina si transportul de oxigen sunt frecvent anormale la bolnavul critic Evaluarea corecta a functiei hemodinamice la bolnavul critic permite o terapie agresiva, goal-directed pentru ameliorarea morbiditatii si mortalitatiiCheatham, Critical Care Refresher Course, 2005, 183-192

Sindroame hemodinamice diagnosticate prin msurarea parametrilor obinui cu CAP

PVCPOAPISRVSHipovolemie Hipervolemie Disfunctie VSNN Disfunctie VDN N Disfunctie biventricularaN Sindrom hiperdinamicN N SIndrom vasoplegic N

Initial resuscitation (1) grade B

The Goals of Initial Resuscitation (during first 6 hours) Surviving Sepsis Campaign, CritCareMed, 2004

CVP(Central Venous Pressure)8 12 mmHgMAP(Mean Arterial Pressure)> 65 mmHgUrine Output> 0.5ml/Kg hScv or SVO2> 70 %

Cateter Swan-Ganz -complicatiiTromboza venoasaTromb intracardiacEmbolie pulmonaraRuptura arterei pulmonareInfectie, SepsisNod de cateterPulmonary artery catheter (PAC) complications, Cruz Lopez 2004

Crit Care Med 2005

PULSION PiCCOSistem pentru masurarea continua a DC, presarcinii, volumul total de apa intratoracica, utilizand analiza conturului undei de puls dupa calibrare prin metoda dilutiei transpulmonare

KT Artriel spcialKT centralveineuxStewart-Hamilton methodPiCCO : principiu2 techniques diffrentes:

thermodilution transpulmonaire: DC moyen lanalyse de londe de pouls : DC batt/batt (=VES)

PICCO

NICOMasoara non-invaziv debitul cardiac bazandu-se pe determinarea de dioxid de carbon expirat, conform principiului Fick

As simple as breathing

Monitorizare non-invaziva metoda impedanteiModificarile impedantei toracice sunt folosite pentru a masura si calcula parametri hemodinamici

Cu fiecare bataie cardiaca volumul sanguin si velocitatea sangelui in aorta se modifica

Sunt masurate modificarile secundare de impedanta

Parametrii masurati

Stroke Volume / Index (SV / SI)Cardiac Output / Index (CO / CI)

Systemic Vascular Resistance / Index (SVR / SVRI)

Systolic Time Ratio (STR)Pre-ejection Period (PEP)LV Ejection Time (LVET)Velocity Index (VI)Acceleration Index (ACI)

Thoracic Fluid Content (TFC)

Ecocardiografia in masurarea debitului cardiacMasurarea debitului cardiac prin doua metodeEstimarea volumelor ventriculare pe baza carora se va calcula volumul de ejectie sistolicaEfectul doppler masurarea velocitatii sangelui ce traverseaza o suprafata vasculara sau valvulara si estimarea secundara a debitului de sangeEcografia transtoracica in evaluarea DC la bolnavul critic are limite: masuratoarea nu este continua, fereastra ecografica poate sa nu fie buna la bolnavul ventilat etc

Doppler esofagianMasurarea non-invaziv a vitezei de scurgere a sangelui n aorta toracic ascendent sau descendenta permite estimarea debitului cardiac (masurare continua)Fluxul sanguin din aorta toracic este identificat pe baza velocitatilor afisate pe ecran i a sunetului caracteristic dat de fluxul aortic Forma curbelor de velocitate permite evaluarea funciei ventriculare stangi, a umplerii sau a postsarcinii ventriculare

Cum functioneaza ?

Excess gainCorrect gain

Intracranial Measurement Methods Intracranial PressureCerebral perfusion pressure (CPP)CPP=MAP-ICP; MAP = mean arterial pressure< or equal to 70 mmHgcontrol ICP & BPJugular Bulb venous oxygen saturation SjvO2 catheter (often fiberoptic) inserted into the jugular bulb< 50% saturationcontrol ICP & CPPBrain Tissue oxygen monitoring PtiO2

Brain Tissue Oxygenation The oxygen electrode is a simple device in which a current proportional to [O2] is generated by polarization of a Pt-electrode to reduce the O2. The configuration used for measuring respiration or photosynthesis is that suggested by Clark (the Clark oxygen electrode), and available in many commercial forms. In this configuration, the Pt-electrode area is kept small, so as to minimize the rate of consumption of oxygen, and the Pt and reference electrodes are separated from the reaction medium by an oxygen permeable membrane."--(A. R. Crofts), University of Illinois at Urbana-Champaign, Biophysics 354; http://www.life.uiuc.edu/crofts/bioph354/lect13.html

Concluzii sistemul ideal de monitorizares urmareasca un parametru crucial dar uor de interpretat s evidenieze modificri ce reflect o agresiune amenintoare de via monitorizarea lui s fie cat mai puin invaziv monitorizare continu dac este cu putin beneficiu mult mai mare decat riscurile pe care le implic monitorul s fie uor de manevrat i cat mai ieftin

A fool with a tool is still a fool

*****Impedance Cardiography is a noninvasive method to obtain hemodynamic information that highly correlates with invasive methods of measuring CO (TD and Fick). (eg. Van De Water)

The curve shown is the Z (or delta Z) reflecting change in impedance (Z) in real time.The change in Z with each heart beat is superimposed on the large baseline impedance, made up of all tissues of the chest. Baseline impedance, Z0, is the reciprocal of TFC, thoracic fluid content.

NOTE: Plethysmography is the act of measuring the size of something. In this case, using electrical impedance, ICG measures change in size of the aorta which is determined by stroke volume.*The hemodynamic parameters measured and calculated by ICG and listed on the Hemodynamic Status Report reflect cardiac flow (output) and the four determinants of cardiac output (HR, preload, afterload, and contractility).

*A flexible probe with a Doppler transducer at its tip is introduce into the mouth , and esophague of a sedated patient. The probe is advanced blindly until you find a signal of descending aortic flow. How do I know what I see is aortic flow?It is an almost exclusively systolic flow with a low velocity in diastole. They are almost no other vessels around (except vena cava, or aortic brances such as celiac trunk .How do I know my signal is OK. 2 criteria: a well defined spectrum with the brightest possible intensity. The brightness reflects the number of red blood cell reflecting US.Prior to acquiring data, you must always ensure that your signal is optimal.