Mazen Kherallah, MD, FCCP Critical Care Medicine and Infectious Disease

 Visual monitoring of respiration and overall clinical appearance  Finger on pulse  Blood pressure (sometimes)

 Invented and popularized the anesthetic chart  Recorded both BP and HR  Emphasized the relationship between vital signs and neurosurgical events ( increased intracranial pressure leads to hypertension and bradycardia )

 Standardized basic monitoring requirements (guidelines) from the ASA (American Society of Anesthesiologists), CAS (Canadian Anesthesiologists’ Society) and other national societies  Many integrated monitors available  Many special purpose monitors available  Many problems with existing monitors (e.g., cost, complexity, reliability, artifacts)

 Manual blood pressure cuff  Finger on the pulse and forehead  Monaural stethoscope (heart and breath sounds)  Eye on the rebreathing bag (spontaneously breathing patient)  Watch respiratory pattern  Watch for undesired movements  Look at the patient’s face color OK? diaphoresis present? pupils

Examples of Multiparameter Patient Monitors

Transesophageal Echocardiography Depth of Sedation Monitor

 Correct ETT placement  ETT cuff pressure  Suctioning  Oxygenation  Ventilation  Airway pressure  Airway gas monitoring  Clinical: wheezing, crackles, equal air entry, color, respiratory pattern (rate, rhythm, depth, etc.)

PurpulYellow

3-4 cm

 Secure ET tube in place, note the number  Sedate patient with appropriate MAAS  Avoid accidental, or self extubation

 These include bedside sphygmomanometers, special aneroid cuff manometers, and electronic cuff pressure devices.  Ideally, most tubes seal at pressures between 14 and 20 mm Hg (19 to 27 cm H2O).  Tracheal capillary pressure lies between 20 and 30 mm Hg  Impairment in tracheal blood flow seen at 22 mm Hg and total obstruction seen at 37 mm Hg

 Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases.  Place a stethoscope over larynx. Indirectly assesses inflation of cuff.  Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration.  Remove syringe tip, check inflation of pilot balloon

What is the amount of light absorbed by the “peak” of the cardiac cycle

 Patient conditions  Carboxyhemoglobin Erroneously high reading may present  Anemia Values as low as 5 g/dl may result in 100% SpO2  Hypovolemia/Hypotension: May not have adequate perfusion to be detected by oximetry  Hypothermia: peripheral vasoconstriction may prevent oximetry detection

 Ambient Light  Any external light exposure to capillary bed where sampling is occurring may result in an erroneous reading  Excessive Motion  Always compare the palpable pulse rate with the pulse rate indicated on the pulse oximetry  Fingernail polish and pressed on nails  Most commonly use nails and fingernail polish will not affect pulse oximetry accuracy  Some shades of blue, black and green may affect accuracy (remove with acetone pad)  Skin pigmentation  Apply sensor to the fingertips of darkly pigmented patients

 Coarse breath sounds  Noisy breathing  Visible secretions in the airway  Decreased SpO 2 in the pulse oximeter & deterioration of arterial blood gas values  Clinically increased work of breathing  Suspected aspiration of gastric or upper airway secretions  Changes in monitored flow/pressure graphics  Increased PIP; decreased Vt during ventilation

Open Suctioning  Disconnection from the ventilator  Not recommended when PEEP >10 Closed Suctioning:  Facilitate continuous mechanical ventilation and oxygenation during the suctioning.  Indicated when PEEP level above 10cmH2O

 Fever  Sepsis  Hyperthyroidism  Agitation  Overfeeding

time Pressure PEEP PIP Pplat Alveolar Distending (recoil) Pressure difference (Pdis) Flow-Resistive Pressure difference (Pres)

Peak Inspiratory Pressure Plateau Pressure

High PIP Normal P Pla t

ProblemManagement Kinked endotracheal tubeAdjust position Patient’s biting on the ETTSedate Excessive SecretionsSuctioning Blocked endotracheal tubeChange BronchospasmBronchodilator

High PIP High P Pla t

 Pneumothorax  Hemothorax  Pleural effusion  Pneumonia  Congestive heart failure  ARDS

Persistent Flow

 Auto PEEP: Dynamic Hyperinflation  Management:  Decrease Tidal Volume  Decrease Insp/Exp ratio Increase inspiratory flow Decrease rate Decrease Inspiratory time

 System leak: Gurgling sound in the neck area  Dislodged ETT  Deflated cuff  Punctured cuff  Bronchopleural fistula: Gurgling sound in the chest area

 Secure your ETT and avoid accidental or self extubation  Will monitor your cuff pressure to avoid tracheal wall pressure injury  Suction you with closed system  Set ventilator alarms to detect variations early  Elevate the head of bed to > 30 º  Use deep venous thrombosis prophylaxis when indicated  Use Stress ulcer prophylaxis

Mazen Kherallah, MD, FCCP Critical Care Medicine and Infectious Disease