BMJ. 2017 Oct 10;359:j4366 Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. Wallis et al. Conclusions : After accounting for patient, surgeon, and hospital characteristics, patients treated by female surgeons had a small but statistically significant decrease in 30 day mortality and similar surgical outcomes (length of stay, complications, and readmission), compared with those treated by male surgeons.

Anesthesia monitoring

Objectives Interpret available clinical data to recognize mishaps or unfavorable system conditions Understanding of the technology of monitoring

Patient Monitoring and Management Involves …

Physiological measurement, such as BP or HR Observation of pupils Endobronchial intubation

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

ASA Monitoring Guidelines STANDARD II During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.

Basic Monitoring Blood Pressure, Heart Rate, ECG Airway Pressure, Capnogram, Pulse Oximeter Temperature Urine output Peripheral nerve stimulator ETT cuff pressure Auscultation Visual surveillance of the anesthesia workspace and some exposed portion of the patient

Special Monitoring PAC TEE ICP EEG PT ABG BIS

Alarms Alarms serve to alert operators

Clinical Anesthesia Monitoring Axis I - Airway /Respiratory Axis II - Circulatory / Volume Axis III - Depth of Anesthesia Axis IV - Neurological Axis V - Muscle Relaxation Axis VI - Temperature Axis VII - Electrolytes / Metabolic Axis VIII - Coagulation

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

Pulse Oximeter Noninvasively measure oxygen saturation in arterial blood. The pulse oximeter probe contains two light emitting diodes at wavelengths of 940nm and 660 nm. Oxygenated and reduced hemoglobin differ in light absorption (940 and 660 nm respectively). Thus the change in light absorption during arterial pulsation is the basis of oximetry determination. The ratio of the absorption at the two wavelengths is analyzed by a microprocessor to record the oxygen saturation.

Artifact: Nail polish Intravenous dyes Diminished pulse

Monitoring ETCO2 Confirms the movement of air in and out of the lungs Reflect alveolar CO2 Indicate adequacy of ventilation

CO2 Increases with: Hypoventilation Malignant hyperthermia Sepsis and fever Insufflation of CO2

CO2 Decreases with: Hyperventilation Low cardiac output pulmonary embolism Circuit disconnect Cardiac arrest

Circulatory Axis COP CVP BP, PAP SVR, PVR

Arterial blood pressure: Indirect/Direct Indirect Bp Contraindication: best to be avoided in patient vascular abnormalities(A-V fistula )

Direct Bp

ECG The electrocardiogram only monitors the electrical activity of the heart and the heart rate Essential for diagnosis and treatment of arrhythmias .

CVP Indications: monitoring CVP for fluid management Infusion of drugs/TPN Aspiration of air embolism Insertion of pacemaker Access for insertion of PAC

CVP Contraindication: Anticoagulation

CVP Complications : Air embolism Infection Thromboembolism Dysrrhythmias Hematoma Pneumothorax , hemothorax Cardiac tamponade Trauma to nearby tissue

Pulmonary artery catheter Indication: to monitor CO, PAP , SVR , mixed venous oxygenation

Anesthetic Gas Monitoring What types/concentrations of gases

Peripheral Nerve Stimulation Neuromuscular blockade

Depth of Anesthesia Clinical Signs EEG monitoring eye signs respiratory signs cardiovascular signs CNS signs EEG monitoring

Bispectral index BIS value 65-85 advocated a measure of sedation BIS value 40-65 recommended for general anesthesia

Temperature Monitoring Indications: Hypothermia Hyperthermia

Electrolyte / Metabolic Axis Fluid balance Sugar Electrolytes Acid-base balance Nutritional status

Coagulation Monitoring Clinical signs PT / PTT / INR ACT Platelet counts Factor assays TEG