Monitoring is a human right. Monitoring is a human right. Anesthetist relies on his/her natural senses to monitor the patient. Anesthetist relies on his/her natural senses to monitor the patient. Simple aids as stethoscope & sphygmomanometer help the anesthetist and may safe the patient. Simple aids as stethoscope & sphygmomanometer help the anesthetist and may safe the patient.

Although the anesthetist is generally careful, conscious and informed, he is usually blamed if a patient dies during or shortly after operation. Although the anesthetist is generally careful, conscious and informed, he is usually blamed if a patient dies during or shortly after operation. However, inappropriate use of monitor may confuse or mislead the anesthetist or distracting him by malfunctioning device. However, inappropriate use of monitor may confuse or mislead the anesthetist or distracting him by malfunctioning device.

At the same time, if the patient dies during anesthesia and he was unattached to an available monitoring device, the anesthetist is legally indefensible. At the same time, if the patient dies during anesthesia and he was unattached to an available monitoring device, the anesthetist is legally indefensible. This is because the concept that, patients who suffer as a result of negligence should be compensated. This is because the concept that, patients who suffer as a result of negligence should be compensated.

So, it is important to use monitor for: Safety. Safety. Conduct of anesthesia. Conduct of anesthesia. ICU practice. ICU practice. Research work. Research work. Assessment of critical conditions. Assessment of critical conditions.

Monitor is a Latin word “ monere ” which means “ to warn ” Monitor is a Latin word “ monere ” which means “ to warn ” Any monitor consists of: Any monitor consists of: 1) Sensor. 2) System for data collection. 3) System for interpretation.

Simple classification of monitoring devices Class sensor data collect. interpret. I Human Human Human II Device Human Human III Device Device Human IV Device Device Device

Degree of invasiveness of monitoring Non invasive e.g. ECG Non invasive e.g. ECG Minimally invasive e.g. I.V cannula Minimally invasive e.g. I.V cannula Penetrating e.g. ECHO Penetrating e.g. ECHO Invasive e.g. Arterial cannula Invasive e.g. Arterial cannula Highly invasive e.g. Brain, heart cannula Highly invasive e.g. Brain, heart cannula

Limitation of monitoring 1) Delay. 2) Danger. 3) Decrease skill. 4) Doubt of results. 5) Distracting set up.

How to select monitor Depend on Depend on 1) Aim. 2) Experience. 3) Type of anesthesia. 4) Facilities & availability. 5) Nature of surgery. 6) General condition of the patient.

CVS monitors Peripheral pulse. Peripheral pulse. Tissue perfusion. Tissue perfusion. ECG. ECG. Arterial blood pressure. Arterial blood pressure. Central venous catheterization Central venous catheterization Pulmonary artery catheterization. Pulmonary artery catheterization. Cardiac output measurement. Cardiac output measurement. TEE. TEE. Blood loss measurement. Blood loss measurement.

Respiratory system monitors Clinical monitors. Clinical monitors. Airway pressure measurement. Airway pressure measurement. Disconnection alarm. Disconnection alarm. Stethoscope (pericordial & esophegeal). Stethoscope (pericordial & esophegeal). Spirometery. Spirometery. O2 monitoring. O2 monitoring. Co2 monitoring. Co2 monitoring. Anesthetic gas analysis. Anesthetic gas analysis. H+ ions measurement. H+ ions measurement.

CNS monitors Clinical monitoring. Clinical monitoring. EEG. EEG. Evoked potentials. Evoked potentials. Cranial nerve monitoring. Cranial nerve monitoring. Cerebral blood flow measurement. Cerebral blood flow measurement. Monitoring of cerebral oxygenation. Monitoring of cerebral oxygenation. Monitoring of depth of anesthesia. Monitoring of depth of anesthesia.

Monitoring of metabolism Temperature monitoring. Temperature monitoring. Tissue oxygenation monitoring. Tissue oxygenation monitoring. Indirect calorimetry. Indirect calorimetry. Fluid & electrolyte status monitoring. Fluid & electrolyte status monitoring. Blood gases & acid base status monitoring. Blood gases & acid base status monitoring. Hormonal status monitoring. Hormonal status monitoring.

Neuromuscular monitoring Clinical tests: 1) Conscious patient. 2) Un Conscious patient. Peripheral nerve stimulation: 1) Single twitch. 2) Train of four twitches. 3) Tetanic stimulation. 4) Double burst stimulation.

Blood pressure monitors ABP= CO×SPR ABP= CO×SPR MAP= Diastolic BP + 1/3 Pulse pressure MAP= Diastolic BP + 1/3 Pulse pressure Pressure units: Pressure units: mmHg (torr) & Kpa & cm H2O (7.6 mmHg= 1 Kpa = 10 cmH2O)

ABP measurement Non invasive BP monitoring: Palpation methode. Palpation methode. Auscultation methode. Auscultation methode. Doppler (U/S) probe. Doppler (U/S) probe. Oscillometry. Oscillometry. Plethysmography (finapress). Plethysmography (finapress). Arterial tonometry. Arterial tonometry.

Invasive BP monitoring: * Indications: * Contraindications: * Technique: - selection of artery: By (allen & modified allen tests). By (allen & modified allen tests). - cannulation technique: - transducer zeroing:

Complications of arterial cannulation Hematoma. Hematoma. Vasospasm. Vasospasm. Thrombosis. Thrombosis. Embolization of air or thrombus. Embolization of air or thrombus. Skin necrosis, infection ….. Skin necrosis, infection ….. Nerve damage. Nerve damage. Disconnection and fatal blood loss ….. Disconnection and fatal blood loss …..

O 2 monitoring (1) Monitor O2 delivery to the patient: O2 failure alarm. O2 failure alarm. O2 conc. In the gas mixture: O2 conc. In the gas mixture: * Fuel cell. * Fuel cell. * Clark electrode. * Clark electrode. * Paramagnetic analyzer. * Paramagnetic analyzer.

(2) Monitor O2 delivery to the tissues A: Global tissue oxygenation: 1- clinical monitoring e.g. 1- clinical monitoring e.g. cap. refilling, state of extremities … cap. refilling, state of extremities … 2- O2 transport monitoring through measurement of: 2- O2 transport monitoring through measurement of: COP & Hb level & SaO2 & PaO2 COP & Hb level & SaO2 & PaO2

3- O2 uptake monitoring through: 3- O2 uptake monitoring through: * measurement of: SvˉO2 by pulmonary artery oximetry. * measurement of: SvˉO2 by pulmonary artery oximetry. * serum lactic acid level. * serum lactic acid level.

(B) Regional tissue oxygenation: 1- Oximetry: * subcutaneous * intravenous * intravenous * cerebral * cerebral 2- Tonomitry : gastric intraluminal tonometry. gastric intraluminal tonometry.

Value: 1- O2 saturation of arterial blood. 2- Heart rate. 3- Tissue perfusion.

Principles: Pulse oximeter probe consists of: - Photosensor. - Photodetector. Based on transmission spectrophotometry & plethysmography. Based on transmission spectrophotometry & plethysmography.

A- Spectrophotometry: According to (Lambert-bear Law) According to (Lambert-bear Law) oxy- & reduced Hb differs in their absorption of red & infrared light. oxy- & reduced Hb differs in their absorption of red & infrared light.

Analyzing these changes of light absorption by microprocessor can identify the value of O2 saturation. Analyzing these changes of light absorption by microprocessor can identify the value of O2 saturation. %saturation = %saturation = oxy-Hb /(oxy-Hb +reduced-Hb) × 100 oxy-Hb /(oxy-Hb +reduced-Hb) × 100

B- Plethysmography: (SpO2) Used to identify arterial pulsation to avoid measuring O2 sat. in non-pulsating blood of viens & tissues. (SpO2) Used to identify arterial pulsation to avoid measuring O2 sat. in non-pulsating blood of viens & tissues.

Disadvantages: Inaccuracy …….if O2 sat less than 70% Inaccuracy …….if O2 sat less than 70% Insensitivity …..significant decrease in PaO2 before significant decrease in SaO2 is detected. Insensitivity …..significant decrease in PaO2 before significant decrease in SaO2 is detected. Interference ….. Interference ….. Intrinsic e.g. co-Hb, Met-Hb, I.V dyes, bilirubine, fetal Hb …… Intrinsic e.g. co-Hb, Met-Hb, I.V dyes, bilirubine, fetal Hb …… Extrinsic e.g. motion, cautery, nail bed infection, polish …… Extrinsic e.g. motion, cautery, nail bed infection, polish ……

CO2 monitoring A- Excretion of CO2 in the tissues by: 1- CO2 (severinghaus) Elctrode. 1- CO2 (severinghaus) Elctrode. 2-Transcutaneous partial pressure of CO2 2-Transcutaneous partial pressure of CO2 B- Excretion of CO2 in the expired gas by: Capnography. Capnography.

Value: Value: 1- Confirm adequate ventilation. 2- Detect esophegeal intubation. 3- Maintain normocapnia. 4- Indicate quality of perfusion.

5- Diagnosis of air embolism, res. Obstruction, arrest & quality of resustation ……… 6- Prediction of awareness, recovery from MR. 7- Assessment of inspiratory valve incompetence …

Principles: Based on infrared absorption spectrophotometery as CO2 absorb light strongly at 4260 nm. Based on infrared absorption spectrophotometery as CO2 absorb light strongly at 4260 nm.Types: 1- Main stream capnography (Flow through) (Flow through) 2- Side stream capnography (Aspiration) (Aspiration)

Definition: Simply, hypoxia means decreased O2 any where; air, blood or tissue. Hypoxemia is the reduction of O2 in the blood resulting in: * PaO2 is < 60 mmHg or * SaO2 is < 90 %

Mean PaO2 = Mean PaO2 = 102 – 0.33 (age in years) ± 10 mmHg (SD) It is an old equation by Marshall and Whyche in, 1972 It is an old equation by Marshall and Whyche in, 1972

These measures must be: These measures must be: - At rest - Breathing room air NB: Neonates hypoxemia occurs when: - PaO2 is < 50 mmHg - SaO2 is < 88 %

With age there is progressive decline of PaO2 That is to say subtracting 1 mmHg from the minimal PaO2 for adult (80 mmHg) for every year over 60 years of age. That is to say subtracting 1 mmHg from the minimal PaO2 for adult (80 mmHg) for every year over 60 years of age.

Types of Hypoxia 1- Hypoxic hypoxia:  When FiO2 < 0.21  Hypoventilation.  Pulmonary V/Q mismatch.  Rt to Lt shunt.

2- Circulatory Hypoxia 2- Circulatory Hypoxia Due to reduced COP. 3- Demand Hypoxia Due to increased O2 utilization.

4- Hemic Hypoxia Due to: decreased Hb content. decreased Hb content. decreased Hb function. decreased Hb function. 5- Histotoxic Hypoxia Due to inability of cells to utilize O2 Due to inability of cells to utilize O2 e.g. cyanide toxicity. e.g. cyanide toxicity.

C/P of Hypoxemia: C/P of Hypoxemia: 1- Cyanosis. 2- Sympathetic stimulation in form of: tachycardia (except ….?) tachycardia (except ….?) hypertension (except ….?) hypertension (except ….?) sweating, arrhythmias, agitation, …. sweating, arrhythmias, agitation, …. 3- Arrest ….in sever persistent hypoxia C/P of the cause.

Prevention and management: Prevention and management: # Prediction from history, exam., investig …… To detect the predisposing factors e.g. 1- Type & site of the surgery …. 1- Type & site of the surgery …. 2- Respiratory diseases ….. 2- Respiratory diseases ….. 3- Smoking 3- Smoking 4- Obesity 4- Obesity 5- Pregnancy 5- Pregnancy 6- Age ….. 6- Age ….. # To do what ? ?

 Good monitoring.  Treatment of the cause.  Sterile equipment.  Humidified gases.  Adequate reversal of NMB.  Proper postoperative analgesia, physiotherapy. # Continue postoperative oxygenation, reintubation, mechanical ventilation may be indicated unfortunately in sever cases.

The following information is obtained Saturday, March 29, 2008 about 21-year-old Dawn Marie Mack Dawn had an abortion performed at National Abortion Federation member of Eastern Women's Center. She was attend, but Dawn went into cardiorespiratory arrest.

The suit said that Eastern staff failed to adequately respond to "the precipitous drop in Plaintiff's blood pressure, cardiac arrhythmia leading to cardiac arrest and cessation of respiration." Dawn was transported to a hospital by ambulance, where staff tried to resuscitate Dawn but, She died.

The suit contended that the following shortcomings caused Dawn's death: * carelessness in hiring staff * negligent supervising of staff * lack of emergency protocol and staff skilled in treating emergencies * lack of adequate equipment * failure to maintain equipment appropriately

* failure to administer timely and properly dosed medications * failure to convey to Dawn the risks of anesthesia * failure to adequately evaluate Dawn's condition via exam and medical history prior to anesthesia * failure to allow sufficient time to administer anesthesia and perform the abortion in a safe and careful manner

* inadequate staff training * inadequate staff training * failure to adequately monitor anesthesia * failure to adequately monitor anesthesia * failure to accurately chart and record observations and responses * failure to accurately chart and record observations and responses * failure to anticipate potential complications * failure to anticipate potential complications So, what ! ! ! ! ! ! ! ! ! ! ! !