1. 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.

2. Anesthesia monitoring

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

5. Patient Monitoring and Management
Involves …

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

7. 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.

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

9. 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

10. Special Monitoring
PAC
TEE
ICP
EEG PT
ABG
BIS

11. Alarms
Alarms serve to alert operators

12. 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

13. 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.)

14. 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.

15. Artifact:
Nail polish
Intravenous dyes
Diminished pulse

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

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

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

19. Circulatory Axis
COP
CVP
BP, PAP
SVR, PVR

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

21. Direct Bp

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

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

24. CVP
Contraindication:
Anticoagulation

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

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

27. Anesthetic Gas Monitoring
What types/concentrations of gases

28. Peripheral Nerve Stimulation
Neuromuscular blockade

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

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

31. Temperature Monitoring
Indications:
Hypothermia
Hyperthermia

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

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