1. 2.11

2. Management of Surgical Emergencies Part 1 : Critical Care
Monitoring in Critical Care
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3. Learning Objectives Why monitor? Where should patients be monitored?
When should patients be monitored?
Methods of monitoring
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4. Monitoring
“Repeated or continuous observations or measurements of the patient, physiological function, and the function of life support equipment, for the purpose of guiding management decisions” [Hudson, 1985]
Systematic approach to monitoring - A,B,C,D,E
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5. Critical Care Monitoring
Why?
Where?
Provide trends to identify improvement or deterioration in patient condition.
Alert caregivers to potentially life-threatening events
Early identification of deteriorating patient
Critical Care environment
HDU / ICU
Theatre & recovery
Emergency Department
General ward???
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6. Methods of monitoring

7. Scenario 0230am – theatre recovery 31 year old male
3 day history of abdominal pain, nausea and anorexia
Pyrexial, tachycardic. Peritonism.
Laparotomy – perforated appendix abscess with contamination
Extubated and self ventilating
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8. AIRWAY MONITORING Observation: Extubated and self-ventilating Talking?
Listen – partial obstruction?
Clearing secretions?
Intubated and ventilated
Capnography
Airway pressures
Fi02
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9. BREATHING MONITORING Observation:
Respiratory rate, effort, accessory muscle use, colour, additional noises?
Pulse oximetry and saturations – limitations
?Arterial blood gas – pH, PaCO2, PaO2
? Capnography – measure end-tidal CO2
Oxygen requirements – FiO2
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10. CIRCULATION MONITORING
ECG monitoring – rate, rhythm
Capillary refill
Colour
Non-invasive blood pressure
Invasive blood pressure – beat to beat blood pressure (? ICU)
Urine output
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11. DISABILITY MONITORING
GCS – Eyes, motor, verbal
Modifications for intubated patients or paediatric patients
AVPU
Pupil response
EEG (specialist)
ICP (specialist)
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12. Temperature – Core v periphery (less perfusion = cooler periphery)
Blood sugar
Lactate
Urine output – 1ml/Kg/hour
Drain output including surgical, chest drains and NG tubes
Fluid balance charts
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13. Oxygen Saturation
SpO2, using a finger or other probe, measures the proportion of saturated to desaturated hemoglobin
Requires adequate perfusion for accuracy
Affected by light, jaundice etc
Not indicator of ventilation
COHb
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14. MEWS Modified Early Warning Scoring Heart rate Systolic Blood pressure
Respiratory Rate
Oxygen Saturations
Temperature
AVPU
Score dependant upon patient physiology - more abnormal physiology = higher score
Useful for identifying deteriorating patient (rising score)
Improved decision making and standardisation of monitoring
Improved clinical practice
Prioritising patients (sicker = higher MEWS)

16. QUESTIONS

17. SUMMARY
Monitoring does not always have to be technical - eyes, ears, hands & brain most useful
Observation and vital signs recording most useful
Easy to perform - untrained staff or family
Trends more useful that single reading
MEWS
Don’t forget the patient!
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