CHAPTER 50

MONITORING DURING ANAESTHESIA

Outline:

Cardiovascular system:
Pulse
Blood pressure
Central venous pressure
The electrocardiograph
Blood loss

Respiratory system:
Tidal volume
Respiratory rate
Colour of blood
Arterial gases
Oximetry
Capnography

Urinary system

Temperature

Neuromuscular blockade

Other parameters monitored in special units

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Monitoring equipment should never replace sound clinical judgment
and common sense. The anaesthetist must always remain with the
anaesthetised patient and must be aware of every problem, surgical and
otherwise, to which the patient is exposed. Good communication with the
surgeon is therefore essential.
The colour of the blood, mucous membrane of the mouth, skin temperature
and the patient's depth of anaesthesia must be constantly monitored.

CARDIOVASCULAR SYSTEM
Pulse
Always make sure there is access to the pulse when the patient is draped.
The radial or the brachial pulse is usually palpated. Note the rate and the
regularity of the pulse, every 5 minutes in the average patient and even
more often in the very ill patient. The volume of the pulse is important. It
is a good habit to place a hand that is free on the patient's pulse whenever
possible. The normal pulse rate in adults varies between 50 and 90 beats
per minute.
Blood pressure (BP)
Measure blood pressure is normally measured with the use of a
sphygmomanometer. Monitor and chart it every five minutes in patients
who are stable and more often in ill patients. Both systolic and diastolic
blood pressures must be recorded. The blood pressure cuff must be wide
enough to cover two-thirds the length of the upper arm.
Palpation method The pressure in the cuff is increased to a point above
which the radial artery is impalpable, then decreased at a rate of 2-3 mmHg
per second. The point at which the radial pulse re-appears is the systolic
blood pressure.
Auscultation method Both systolic and diastolic blood pressure are
obtained by this method. The systolic blood pressure is about 10 mmHg.
above that obtained by the palpation method.
Oscillotonometer. The blood pressure may be recorded by noting the
oscillations of a needle in the oscillotonometer.
Automatic electronic devices are commonly used today.
The normal blood pressure varies. For an adult it is 100/70 to 140/90, while
for babies and small children it is 80 or 90 systolic and increases gradually
with age.

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Central venous pressure (CVP)
The CVP is the pressure in the venous side of the circulation measured by a
catheter inserted into the large veins opening into the heart. Normal CVP is
from 5 to 10 cm of water.
About 80% of the blood volume is contained in the venous circulation, so
when the blood volume falls, the venous pressure falls. Venous pressure
falls before arterial pressure. The measurement of the venous pressure
gives us an early indication of blood loss. If the patient has been transfused
and the blood volume has been increased, the venous pressure rises. The
venous pressure also rises if the heart is failing. When the heart action fails
there is a banking up of blood on the venous side of the circulation. The
central venous pressure should always be interpreted together with the other
parameters monitored - arterial blood pressure, pulse, peripheral circulation,
etc.
Guide to CVP measurements

CVP BP Diagnosis Fluids Drugs

Low Low or Fluid Lack Increase
normal

High Normal Fluid overload Reduce Diuretics

e.g. frusemide

High Low Cardiac Failure Restrict Diuretics

Digoxin-
(for rapid AF)
IV inotropes
eg dobutamine

Indications for CVP monitoring

• Whenever massive infusions or transfusions are given
• In severe shock
• In patients with heart failure receiving fluid therapy
• In acute cardiac failure of obscure origin.

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 The Electrocardiograph (ECG)
The ECG gives an accurate assessment of:
• Rate
• Rhythm of the heart
• The degree of oxygenation of the heart muscle. Hypoxia may show as
a change in the ST segment. Ideally, all patients anaesthetised should
be monitored electrocardiographically.
The ECG is especially useful in:
• Patients with heart disease such as arrhythmias, ischaemia,
hypertension, heart failure
• Patients who have a previous history of anaesthetic problems
• Patients who are shocked, hypotensive or bleeding
• Patients who are poor risks due to underlying medical conditions, e.g.
thyrotoxicosis, diabetes, renal or liver disease.

Blood loss
Blood loss can be measured by several methods:
The gravimetric method: The swabs, sponges and packs are weighed dry
and then with the absorbed blood. The difference in weight gives the
weight of the blood absorbed. One gram of blood is then taken to be equal
to 1ml of blood. To this weight is added the volume of blood in the suction
bottles. A further 25% should be added to the total to account for the blood
in the drapes, etc.
Colorimetric method: The swabs and sponges are mixed with a large
known volume of liquid and the haemoglobin level of the resultant solution
is estimated. By using a formula the blood loss may be worked out.

RESPIRATORY SYSTEM
Tidal volume
To estimate the tidal volume you need a spirometer.
A Wright’s respirometer is commonly used as it is small, portable and does
not require any power supply. The gas flow drives a spinning vane in one
direction only and the speed of rotation is converted to volume which is
then displayed on a dial.
The Respiratory Rate
This should be noted, especially in the case of spontaneous respiration.
Colour of blood
This must be constantly observed. It shows how well oxygenated the
patient is and therefore gives an idea of the respiratory and cardiovascular
systems but is not nearly as accurate as pulse oximetry.
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Pulse oximetry
Arterial oxygen saturation (SaO2) is the measure of oxygenation of the
blood. The relationship between oxygen saturation of haemoglobin (Hb)
and the partial pressure of oxygen in the blood is not linear (See Respiratory
physiology in Chapter 3). As saturation drops below 80% partial pressure
drops dramatically. Any value below 90% is clinically dangerous.
A small sensor is placed on the end of the finger, toe or ear lobe. The sensor
consists of 2 light-emitting diodes one red and one infrared illuminating in
turn. They emit light of 650 nanometers for oxyhaemoglobin (HbO2 ) and
900 nanometers for reduced or de-oxyhaemoglobin (Hb). The blood absorbs
this light depending on the content of HbO2 & Hb. The photo diode detects
the residual light energy. This is interpreted as a Hb/HbO2 ratio and the
resultant SaO2 is calculated and presented on the machine. The pulse
oximeter depends therefore on the pulsatile perfusion of the tissues and so
doubles up as a pulse meter. Pulse oximetry must be interpreted with
caution in the following conditions:
When abnormal Haemoglobins are present
• Carboxyhaemoglobin (smokers may have 10-20 % carboxy Hb). The
pulse oximeter does not distinguish between oxyhaemoglobin and
carboxyhaemoglobin and in heavy smokers the reading will be falsely
high.
Following poisoning with carbon monoxide a pulse oximeter is very
inaccurate.
• Methaemoglobin. This is normally only 1% but it rare cases can reach
levels of over 20%. Methaemoglobinaemia can be caused by certain
drugs e.g. nitrites, sulphonamides and prilocaine and some poisons. It
can also occur spontaneously. It is of importance to the anaesthetist as
it reduces the oxygen carrying capacity of the blood and shifts the
oxygen dissociation curve to the left. Treatment is with methylene blue
1% given IV at a dose of 1–2mg / kg over 5 mins.
When limb blood flow is low
• Low blood pressure
• Hypothermia
• Vasoconstriction from any cause
• Peripheral vascular disease.
Miscellaneous causes
• High intensity light
• Heat lamps
• IV dyes such as methylene blue
• Electrocautery
• Venous congestion.

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 Capnography
A capnograph measures carbon dioxide in inspired and expired gases using
infra–red absorption. The information can be displayed in numerical form
or as a waveform or capnograph tracing.
Hypercapnia (also called hypercarbia) means an abnormally high carbon
dioxide.
Hypocapnia (also called hypocarbia) means an abnormally low carbon
dioxide.
Carbon dioxide is produced in the tissues as a result of cellular metabolism.
It is carried from the tissues in the venous blood to the right side of the heart
and from there into the lungs via the pulmonary artery. The pulmonary
arterioles perfuse the alveoli of the lung. The carbon dioxide diffuses from
the arteriole into the alveolus and via the expiratory gases through the upper
airway into the atmosphere.
If this process of elimination is interfered with, carbon dioxide accumulates
in the blood stream (See Chapter 3 Respiratory failure).
The closer to the alveoli we sample the gas, the more accurately will the
sample reflect the changes in the alveoli and in the blood stream.
Methods of sampling of end-tidal CO2
Mainstream The gas is analysed as it passes through the circuit.
Sidestream Here the gas is led through a small capillary tube to a
capnograph and then analysed. Hence a slight delay in analysis.
Principle of carbon dioxide measurement
This depends on infra-red absorption. An infra-red light beam is projected
through a gas source and the intensity of transmitted light is measured. The
difference will indicate the amount of carbon dioxide absorbed.

Fig 50.1 Capnograph tracing

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The normal capnograph is shown in the diagram. Any significant change
indicates respiratory abnormality, a mechanical defect in the circuit or a
complication.
Description of the capnograph
Phase b (2nd phase ascending part) represents exhalation. Carbon dioxide
builds up during exhalation as the gases containing it are expired from the
alveoli into the atmosphere via the sensor.
Phase c (3rd phase plateau) This remains nearly constant until the next
inspiration sweeps the carbon dioxide away.
Phase d (4th phase descending part) The fresh gas flow entering the lungs
during inspiration contains no carbon dioxide. The carbon dioxide level
falls rapidly to the base line, indicating the start of inspiration.
Phase a (1st phase) The capnograph remains steady at zero, indicating
inspiration.
How to interpret the capnograph
Phase b abnormal A slanted upstroke means
• Uneven emptying of the lungs. Carbon dioxide rises at different times
(a gradual rise).
• The sampling mechanism is too slow.
Phase c The Plateau.
Normal peak values are 36 - 44 mmHg. The highest carbon dioxide is
found at the end of expiration and is called the End tidal carbon dioxide
(EtCO2)
High plateau (greater than 44 mmHg) may be caused by
• Hypoventilation:
− The effect of anaesthesia and opioids on the spontaneously
ventilating patient
− Respiratory failure (see Chapter 57)
• Increased production of carbon dioxide, secondary to malignant
hyperpyrexia, fever.
• Transient increase in carbon dioxide:
− Release of limb tourniquets after surgery
− IV sodium bicarbonate (NaHCO3)
− Insufflation of carbon dioxide – laparoscopy
Low plateau (less than 36 mmHg)
• Hyperventilation (normal minute volume 100 - 120 ml/kg)– caused by
hypoxia, fever, (hysteria in awake patient).
• Low carbon dioxide delivery to the lungs:
− Hypotension
− Pulmonary embolus
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 − Decreased cardiac output from any cause.
Irregular plateau indicates a physiological cause - a dip showing an attempt
to breathe spontaneously e.g. muscle relaxant wearing off.
Slanted plateau indicates COAD or asthma.
Shorter plateau indicates a leak in the system.
Phase d Slanted downstroke
Normally the downward slant is very brisk (almost vertical). If it is slow it
may mean there is carbon dioxide in the inhaled gases, or the inspiratory
valve is not functioning properly.
Phase a
An abnormal base line means the inspired air contains carbon dioxide.
Uses of Capnography
• Confirming intubation of the trachea. A normal capnograph indicates
tracheal intubation. There is no carbon dioxide detected with
oesophageal intubation.
• Apnoea. The capnograph alarms when the next wave of carbon dioxide
fails to arrive. This reveals apnoea from whatever cause (i.e. airway
obstruction, drugs such as excessive opioid usage or inadvertent
muscle relaxant etc.).
• Warning of a disconnection in the circuit.
• Measuring the adequacy of mechanical ventilation.
• Diagnosis of rebreathing.
• Measuring the adequacy of cardiac output (i.e. PE or cardiac event
such as acute myocardial infarction).
• Early detection of malignant hyperpyrexia.

URINARY SYSTEM
The urine output is measured every hour if the patient is catheterised.
A good urine output is 60 ml/hr in an adult or 1 ml/kg/hr in a child.
Minimum urine output should be 30 ml/hr or 0.5ml/kg/hr.

TEMPERATURE
This should be checked routinely in very young patients. The temperature
should be monitored in several other groups of patients, e.g. febrile patients,
those having major or prolonged surgery.
• Rectal temperature. This only poorly reflects central body temperature.
• Oesophageal temperature. A probe is inserted into the naso-pharynx or
into the upper oesophagus between the heart and the descending aorta.

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This reflects the temperature in the central circulation.

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 NEURO-MUSCULAR BLOCKADE
A peripheral nerve stimulator is used for monitoring neuromuscular
function, the aim being to provide optimum recovery from paralysis after
anaesthesia. A nerve stimulator applies a current to a peripheral nerve and
measures the response in the muscle that the nerve supplies.
The features of the nerve stimulator are:
• The pulse waveform is a unipolar square wave of 0.2 - 0.3 ms duration.
• The output from the nerve stimulator should provide supra-maximal
stimulation (more than 50 mA). That means a current is applied which
guarantees every muscle fibre to be stimulated with each pulse.
• Stimulus patterns Single twitch (1.0 Hz)
Tetanus (50 Hz)
Train of four
Double burst.
These are discussed a little later. A digital print-out is useful.
Site of stimulus
The ulnar nerve is commonly used. The muscle observed is the adductor
pollicis which is innervated solely by the ulnar nerve.
Setting up
• The electrodes should be positioned as close as possible to the nerve.
• There are two types of electrodes - surface and needle. Surface
electrodes are generally used. Needle electrodes are useful in the
obese, those with thick skin and burns patients.
• Preparation of skin involves:
− Removing excess hair using a razor.
− Light abrasion of the skin.
− Cleansing with alcohol.
• Placement of electrodes:
− Place the distal electrode, which is connected to the negative
(black) terminal, 1-2 cm proximal to the proximal skin crease,
just lateral to the tendon of the flexor carpi ulnaris.
− Place the proximal electrode as close to the distal electrode as
possible along the line of the ulnar nerve (3 - 4 cm apart).
Baseline adjustment
Before administering the muscle relaxant, adjust the nerve stimulator to
provide supramaximal stimulation, which means the level of stimulation at
which all the muscle fibres are depolarised. Increasing the current above
this level does not increase the twitch response. Once this setting has been
found for the patient, it should be kept for the entire procedure.

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Monitoring the neuromuscular function
Twitch response The stimulus is delivered at a rate of 1 per second. After
the relaxant is given the twitch response starts to fade. The twitch may
completely disappear, which means more than 90% of receptors are
blocked. However, it is better not to abolish the twitch completely under
anaesthesia but to give just adequate amounts of relaxants to maintain a
faint visible muscular contraction.
If the twitch has been abolished by an overdose of relaxant, wait until it
reappears before giving a subsequent dose or reversing the patient.
Tetanic stimuli When the simple twitch returns to normal one can say that
20% of the receptors are free. But this also means that 80% of the receptors
are blocked and this is dangerous, so we cannot rely on the twitch response
to tell us if recovery is adequate. The tetanic stimulus was designed for this
purpose: 50 or 100 stimuli per second (Hz) are delivered for 5 seconds. This
rapid stimulation depletes the neuromuscular junction of acetylcholine
when the number of free (unblocked) receptors is decreased. The tetanic
response gets less and less, that is, it fades.
The higher the rate of stimulation the more obvious the 'fade'. Although
tetanic stimulation is a means of assessing recovery it is painful and
therefore of limited value in the unanaesthetised patient.
Train of four (TOF) stimuli The nerve is stimulated with 4 supramaximal
currents 0.5 of a second apart. The response can be assessed in the form of
the TOF count (TOFC) or the TOF ratio (TOFR). The TOFC indicates the
number of palpable or visible twitches after the TOF stimulation. When a
patient is paralysed with a muscle relaxant the twitches are lost in the order
4-3-2-1.
During recovery from the relaxant the 1st twitch reappears first and the
others follow. When only 1 twitch is present after TOF stimulation it means
there is 90% block. This is a good level of relaxation to maintain for
surgery.
It is important not to completely abolish the thumb twitch (TOFC = 0). This
would indicate too much relaxant.
Recovery from the block occurs when the TOFC is 4 and all the twitches
are of equal height.

Double burst stimulation (DBS) This pattern of stimulation is available on

the newer nerve stimulators. It consists of 2 short bursts of tetanus (50Hz
for 60ms) separated by 0.75 of a second. It is easier to see fade on DBS than
using TOF. DBS is more useful in the post-operative and recovery phase
than TOF.

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The Post-tetanic count (PTC) is sometimes used to assess deeper levels of
block when all response to TOF stimulation is absent (no twitching at all). It
consists of 50Hz for 5 seconds, (like the tetanic stimulus mentioned earlier),
a 3 second pause and then a single twitch. The PTC is the number of visible
twitches. One (1) means deep block; 2-8 moderately deep.

Clinical application
Induction TOFC 1 Good relaxation sufficient for laryngoscopy.
PTC 0-1 Paralysis of diaphragm if required in special
conditions.
Maintenance TOFC -1 (90% depression of single twitch)
Stimulate with TOF every 5 – 15 minutes
and seek to maintain a TOFC 1. If there is
no response to TOF a PTC is performed.
Reversal Aim to have the TOF at 3 - 4 by the time of reversal.
If before reversal the TOFC is 0 the patient should not be
reversed but simply ventilated and kept anaesthetised. If
the TOFC is 1 - 2, neostigmine plus atropine (or
glycopyrrolate) is used and the patient must be carefully
observed for up to 30 minutes for complete recovery.
Recovery The simplest test for adequate recovery is the sustained
head lift for 5 seconds.
Using the nerve stimulator:
• A TOFC of 4 and all 4 twitches are the same height.
• A sustained response to tetanus. If you cannot detect
a fade, use a DBS or 100Hz tetanus for 3-5 seconds.
Any detectable fade will imply residual muscle
paralysis.

Possible errors in monitoring blockade

• Technical error
• The presence of nerve and muscle disease

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 OTHER PARAMETERS MONITORED IN SPECIALISED
UNITS

Cardiac output, pulmonary artery pressure, arterial blood gases,

electroencephalogram (EEG) and blood volume can all be measured using
electronic equipment. Monitoring of these parameters is not routine but
there are specific conditions where they are useful. This type of monitoring
would normally be carried out in an Intensive Care Unit. For more detailed
information see an advanced textbook of anaesthesia or intensive care
medicine.

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