1. Monitoring of Patients during Anesthesia and Surgery Haim Berkenstadt MD Director, Department of Anesthesiology Deputy Director, The Israel Center for Medical Simulation Sheba Medical Center, Tel Hashomer April 2009

2. Agenda Requisites from anesthesia monitoring Physiological changes during anesthesia Complications of anesthesia Monitoring of specific physiological systems Generic considerations of monitoring

3. Monitoring? Physiological data Relevant On line measurement Continuous measurement Influence medical decision making Improve patients safety Cost effective

4. Physiological Changes During Anesthesia and Surgery Respiratory Changes Hypoventilation Hypoxemia Hemodynamic changes Preload Afterload Contractility

5. Physiological Changes During Anesthesia and Surgery Changes in neuromuscular function Changes in fluids balance Bleeding ADH Changes in heat exchange Exposure Vasodilatation

6. Complications of Anesthesia Common Damage to teeth Nausea and vomiting Pain Hypothermia

7. Complications of Anesthesia Life threatening Esophageal intubation Cardiac Respiratory Anesthesia machine malfunction Post operative residual neuromuscular blockade Awareness during anesthesia

8. Anesthesia Monitoring System

9. ECG

10. Heart rate Heart rhythm Myocardial ischemia

11. Blood Pressure Non invasive blood pressure measurement Invasive blood pressure measurement

12. Non Invasive Measurement What do we measure? Where to measure? Cuff size? Interval?

13. Invasive Blood Pressure Measurement

14. Pulse Oximetry Oxygen saturation Heart rate Plethysmography

15. Capnography Mechanically ventilated patient / Spontaneously breathing patient Side stream / Main stream

16. Capnography Respiratory rate End tidal CO2 Endotracheal intubation Cardiac output

17. Temperature - Core Body Temperature

18. Thermoregulation under Anesthesia

19. Consequences of Hypothermia Hemodynamic effects Coagulation Surgical wound infection Cardiac morbidity Metabolism of drugs Shivering

20. Temperature Measurement When? Where? Skin Esophageal Urine Blood

21. Neuromuscular Monitoring Nerve stimulator Electrical stimulus Measurement of motor response

22. Urine Output Volume status Increased urine output

23. Prevention of Awareness during Anesthesia

25. Gas Analyzer

26. Ventilation

28. Invasive Monitoring Central Venous Pressure, Pulmonary Capillary Occlusion Pressure, Cardiac Output, Intra-Cranial Pressure

29. Trans-esophageal Echocardiography

30. EEG

31. Monitoring Alarms Adaptation to Age and patients’ normal values Borders of safety Balance between Safety False alarms

32. Trends of Parameters

33. Documentation

35. Thank you Haim.berkenstadt@Sheba.health.gov.il 03-530-2966