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Critical Care Monitoring

BY Dr Ezzat El Taher 2004

What is monitoring? The verb monitor (derived from the Latin monere, to warn) means to check systematically or to keep watch over. In the context of anesthesiology and the ICU monitoring means using both our senses and electronic devices to repeatedly or continuously measure important variables in the monitored patient. Where to monitor ? In The ICU: In The OR : In The ER : During Transportation : To Hospitals I-Clinical monitoring II-Hemodynamic Monitoring 1-Arterial Blood Pressure (Noninvasive., Invasive) 2-The electrocardiogram (ECG) 3-Central venous pressure Central Venous Catheter 4-Cardiac output &other Hemodynamic parameters: Pulmonary Artery Catheter.

III- Respiratory Monitoring 1-Precordial & Esophageal Stethoscopes 2-Oxygen Saturation (Pulse Oximetry) SpO2 3- End Tidal Carbon dioxide (capnogrephy or capnometry ) 4-Transcutaneous O2 & CO2 monitoring

III- Neuronal monitoring

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1-Sensory-Evoked Potentials (SEPs) 2-The electroencephalogram (EEG) 3-The cerebral function monitor (CFM) 2-Intracranial pressure Monitoring (ICP) IV- Miscellaneous Monitoring : 1-Temperature Monitoring. 2-Urine output Monitoring 3-Neuromuscular Monitoring 4-ABG and Electrolytes Monitoring 5-Monitoring of a Ventilated patient: airway pressure, ventilatory volume, disconnection alarms 6-Monitoring of blood loss I-Clinical monitoring The various senses of the attending doctor are the primary equipment for clinical measurement. The attending doctor should also develop a sixth sense, a subconscious mental computation of observations, time and experience, which warns of impending events and prompts action to meet the needs of the patient. Simple observations which can be made and their relevance include the following:1 -Colour of skin and blood ---- oxygenation. 2 -Temperature of skin ---- body temperature, circulatory status, fluid balance, acid-base status. 3 -Pulse character and rate -cardiac performance and ABP. 4 -State of peripheral circulation ---- circulatory status. 5- Degree of filling of jugular veins ----circulating volume.. 7 - Respiratory movement --- adequacy of lung ventilation. 8- Muscle tone and movement - relaxation. 9- Clotting time of blood (collected in glass test tube and kept warm in the hand while timing clotting). II- Hemodynamic Monitoring 1-Arterial Blood Pressure (ABP) A-Noninvasive. B-Invasive 2-The electrocardiogram (ECG) 3-Central venous pressure (CVP) C .Venous Catheter
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4-Cardiac output &other Hemodynamic parameters and indices ) Pulmonary Artery Catheters 1-Arterial Blood Pressure (ABP) The rhythmic contractions of the left ventricle result in pulsatile arterial pressures. The systolic blood pressure (SBP): The peak pressure generated during systolic contraction. And it is necessary for calculation of the MAP The diastolic blood pressure (DBP): The trough pressure during diastolic relaxation . And it is useful for estimating coronary flow. The mean arterial pressure (MAP): The time weighted average of arterial pressures during a pulse cycle. It is important for estimating organ perfusion, especially renal . M AP = (SBP) + 2(DBP) 3 = D+1/3(S-D) Measurements of ABP are affected: by: 1-The sampling site: -For example, radial artery systolic pressure is usually higher than aortic systolic pressure because of the former more distal location. 2-The level of the sampling site relative to the heart will alter measurement of blood pressure because of the effect of gravity. (direct or indirect) A- Noninvasive (Indirect) ABP Monitoring: The Methods: Palpation Doppler Probe Auscultation OscillometryPlethysmography or

2- Doppler Probe:

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useful in obese patients, pediatric patients ,and those who are in shock . only systolic pressures can be reliably determined with the Doppler technique. 3-Auscultation: Inflation of a blood pressure cuff to a pressure between systolic and diastolic pressures will partially collapse an underlying artery, producing turbulent flow and the characteristic Korotkoff sounds. -SBP coincides with the onset of Korotkoff sounds; - DBP is determined as their muffling or disappearance. -Motion artifact and electrocautery interference limit the usefulness of this method. 4-Oscillometry: Arterial pulsations cause oscillations in cuff pressure. Maximal oscillation occurs at the mean arterial pressure, after which oscillations decrease. -Automatic oscillotonometer : -A cuff is inflated automatically at preset intervals, to above the previous systolic pressure. as the cuff pressure is steadily reduced below the systolic and then diastolic figures are detected by a transducer in the monitor, analysed, and presented as systolic, diastolic and a computed mean arterial pressure 5- Plethysmography: Arterial pulsations transiently increase the blood volume in an extremity. -A finger photoplethysmograph, consisting of a light emitting diode and a photoelectric cell, detects changes in finger volume. - The Finapres (finger arterial pressure) plethysmograph continuously measures the minimum pressures required in a small finger cuff to maintain a constant finger volume. -Plethysmography has proved unreliable in patients with poor peripheral perfusion (eg, those with peripheral vascular disease or hypothermia). Clinical Considerations in ABP : -Arterial blood pressure should be viewed as an indicator but not a measure of endorgan perfusion. -The cuff's rubber bladder should extend at least halfway around the extremity,
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The with of the cuff should be 20-50 % greater than an the diameter of the extremity. A conventional cuff overestimates arterial pressure on a fat or muscular arm, and underestimates it on a thin arm or on the arm of a .child. Techniques that rely on a blood pressure cuff best avoided in extremities with vascular abnormalities (eg, dialysis shunts) or intravenous lines. Low alarm limits are often set at 2/3 of the baseline values to give warning for action before the pressure reaches the limit of half the baseline value. High limits are often set at 4/3 of the baseline values. B. Invasive (Direct) ABP Monitoring. (Arterial Line ) Indications of Arterial Cannulation (Arterial line) -Direct ABP Monitoring in: -Elective hypotension. -Anticipation of wide intraoperative ABP swings, -End-organ disease necessitating precise beat-to-beat BP regulation. -Multiple analyses of arterial blood gases (ABG). Catheterization should be avoided : -In arteries without documented collateral blood flow. -Extremities: preexisting vascular insufficiency ( Raynaud's disease) Arterial Line . Technique Arterial Line .set Complications: of arterial cannulation: Hematoma, Vasospasm, Thrombosis, Nerve damage, Infection, Loss of digits, Embolization of air bubbles or thrombi, skin necrosis overlying the catheter, and unintentional Intra-arterial drug injection. Factors increased the rate of complications include prolonged cannulation, hyperlipidemia, repeated insertion attempts,

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Radial artery cannulation is a low-risk, high-benefit method of patient monitoring. The risk of ischaemic complications slight.

-The dorsalis pedis artery is also a convenient site giving similar pressures to the aorta. Clinical Considerations -Direct ABP measurement is considered the gold standard of blood pressure monitoring techniques. (continuous and beat-to-beat monitoring) Allen's test may be used to detect adequate ulnar artery collateral circulation. The hand is exsanguinated by the patient making a fist actively (or passively when unconscious) while the radial artery is occluded and the palmar flush of blood from the ulnar artery observed on opening the hand. (+ve <5 s. ,-ve>10s.) 2-The electrocardiogram The ECG is a recording of the electrical potentials generated by myocardial cells. Allows the detection of dysrhythmias, myocardial ischernia, conduction abnormalities, pacemaker malfunction, and electrolyte disturbances. It does not afford a measure of the efficiency of myocardial contraction or of cardiac output; in fact normal electrical activity may occur when there is no cardiac output. lead II for the diagnosis of dysrhythmia and detection of inferior wall ischemia . Lead V5 ,is a good for detecting antrolateral or /and lateral wall ischemia. For routine monitoring three electrodes are placed on the chest, as near to the heart as convenient. The ECG is liable to artifacts that can simulate dysrhythmias may be caused by : -Disconnection of an electrode, -Improper earthling of apparatus, -Patient or lead-wire movement,
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-Electrosurgical units, -Faulty electrodes 3- Central Venous Pressure (CVP) The term central venous pressure (CVP) refers to the pressure in the right atrium or the intrathoracic inferior or superior venae cavae. Normal CVP : 3-10 cmH,O . High values may indicate : Right ventricular failure, Pulmonary embolism, Tamponade, or Misplacement of the catheter tip into the right V. or pulmonary artery. Low value indicate: Hypovolaemia .Shock Central venous pressure measurements are not a good guide to daily fluid requirements and should not be used for this purpose. A patient can' easily be waterlogged or dehydrated in the presence of a normal CVP. The zero must be a chosen reference level, i.e. the mid-axillary line or the manubriosternal angle. Measurement of central venous pressure is made with a water column (cm H20) or, preferably, an electronic transducer (mm Hg) Central Venous Catheterization Indications: 1-Monitoring of CVP for the fluid management of hypovolemia and shock, 2-Infusion of caustic drugs and hyperalimentation, 3-Aspiration of air embolism, 4- Insertion of transcutaneous pacing leads, 5-Gaining venous access in patients with poor peripheral veins

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Cannulation Sites.: the subclavian vein : low incidence of bacteremia, The right internal jugular vein: accessible and safe Complications Thrombophlelibits, Septicaemia; Haemothorax; Brachial plexus injury; Pericardial effusion; Catheter breakage; Infection, Pneumothorax: Hydrothorax; Air embolus; Lymph leakage; Arrythmias.

4-pulmonary artery catheter (PAC) or Swan - Ganz catheter: for cardiac output Monitor These are balloon-tipped, flow-directed flexible catheters, originally used for measuring Cardiac output, Thermodilution technique Pulmonary Capillary wedge Pressure (5-10 mmHg) (PCWP) Indications of PAC insertion : Low cardiac output; pulmonary oedema; septic shock; and to sample mixed venous blood. Other methods of estimating cardiac output : 1-Doppler ultrasound: records velocity flow and crosssectional area of aorta for single beats, (multiplied by pulse rate for output) . 2-Aortovelography : estimates the changes in output. 3-Thoracic impedance :difficult in children. 4-Combined ultrasound and Doppler probes 5-Echocardiography gives an important measure of left ventricular ejection fraction, wall motion abnormalities and gradients across valves. 6-Transoesophageal echocardiography is a clinically useful tool, giving information on wall motion abnormalities and ventricular function.. III-Respiratory Monitoring
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1-Precordial & Esophageal Stethoscope 2-Oxygen (Pulse Oximetry) SpO2 3-Carbon dioxide (capnogrephy or capnometry ) for end tidal CO2. 4-Transcutaneous O2 & CO2 monitoring

A precordial stethoscope is, bell-shaped piece of metal placed over the chest or suprasternal notch. -The esophageal stethoscope is a soft plastic catheter (8-24F) with balloon-covered distal openings. The information provided by a precordial or esophageal stethoscope includes: - confirmation of ventilation, - quality of breath sounds (eg, wheezing) - regularity of heart rate ,and - quality of heart tones. Instrumentation of the esophagus should be avoided in patients with esophageal varices or strictures. 2- PULSE OXIMETRY oxygen saturation SpO2 The lobe of the ear, bridge of nose, or finger is placed between a two-wavelength light source and a detector. Readings are indicated as analogue or digital displays. Spo2: Normal close to 100% -- 90% indicate pao2 <65 Clinically detected cyanosis need 5 gm of desaturated Hb correspond to Spo2 < 80%

Limitations of pulse oximetry 1- Weak arterial pulsation and poor peripheral perfusion ( vc)
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2- Carboxyhaemoglobin False +ve 3-Bilirubin causes under-reading. 4- Polyeythaemia of cyanotic congenital cardiac disease. 5- Excessive movement or diathermy. 6-Nail varnish (weak signal). 7- Strong ambient light." 8- Electronic failures 3-Carbon dioxide (capnogrephy or capnometry (ETCO2) End tidal CO2: The highest CO2, content is found at the end of expiration, and is called the end-tidal CO2 A continuous sample of respired gas is withdrawn from breathing systems in anesthetized patient or in ventilated patient in intensive care unit and the CO2 content displayed on a continuous recorder of ETCO2 as either :

Capnography (ETCO2) can help in : I -Careful control of CO2 levels; (adequacy of V.) 2- Warns of airway, intubation and ventilation errors; 3- Monitors special dangers such as air embolism, sudden changes in cardiac output. shock, malignant hyperpyrexia. etc.; 4 Warns of inspired CO2 rising (e.g. rebreathing); 4-Transcutaneous O2 and CO2 Monitoring Actually measure cutaneous partial pressures, which approach arterial values if cardiac output and perfusion are adequate Useful in the management of many critically ill patients and in in pediatric intensive care units. Has not gained the popularity of pulse oximetry because of its warm-up time, difficulties of sensor maintenance, and complexities of interpretation. III-Neuronal monitoring 1- Evoked Potentials.
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(SEPs) 2-The electroencephalogram. (EEG) 3-The cerebral function monitor. (CFM) 4- Intracranial Pressure Monitoring (ICP) III-Neuronal monitoring 1- Evoked potentials (EPs) Used for testing neuron integrity during spinal, cardiac and carotid surgery, Commonly monitored evoked potentials are visual, auditory, and somatosensory. 2-The electroencephalogram EEG 1- To assess sedation and awareness. 2- To monitor epileptic activity, in paralysed patients. 3-Confirm the adequacy of cerebral oxygenation during cerebrovascular surgery, 4- Monitoring the depth of anesthesia 5- To monitor changes in conscious level. 3-The cerebral function monitor (CFM) Used to monitor 1-Depth of anesthesia and sedation, 2-Cerebral ischaemia during cardiopulmonary bypass 3-Coma levels in the ITU IV-Miscellaneous Monitoring 1-Temprearture Monitoring Indicated In :all critically ill patient in ICU and all patients undergoing general anesthesia . Hypothermia: a body temperature less than 36 C: - occurs frequently during anesthesia and surgery. -reduces metabolic oxygen requirements, so -protective during times of cerebral or cardiac ischemia. Hypothermia has several Deleterious effects - Cardiac dysrhythmias -Increased peripheral vascular resistance
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-Left shift of the hemoglobin-oxygen saturation curve -Reversible coagulopathy (platelet dysfunction) -Postoperative protein catabolism and stress response -Altered mental status -Impaired renal function -Decreased drug metabolism -Poor wound-healing Shivering increases oxygen consumption as much as fivefold, decreases arterial oxygen saturation, risk of myocardial ischemia and angina. In extremes of ages and in critically ill patients Monitoring site for Temperature: 1-The tympanic membrane :reflects brain temperature. 2-Rectal temperatures have a slow response to changes in core temperature. 3-Nasopharyngeal probes are prone to cause epistaxis but accurately measure core temperature 4-The thermistor on a pulmonary artery catheter also measures core temperature: 5-Liquid crystal adhesive strips placed on the skin are inadequate indicators of core body temperature during surgery. 6- Esophageal temperature sensor incorporated with esophageal stethoscope: 2-Neuromuscular Monitoring PERIPHERAL NERVE STIMULATION Indicated in: all patients receiving muscle relaxants in OR or in ICU ,.

Peripheral nerve stimulators can help to locate nerves to be blocked by regional anesthesia and determine the extent of sensory blockade. A peripheray nerve stimulator delivers a current of variable frequency to a pair of electrodes placed over a peripheral motor nerve.

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3-Urine output Urinary bladder catheterization Urine output is a reflection of kidney perfusion and function. It is an indicator of renal, cardiovascular, and fluid volume status. Oliguria :defined as urine output of less than 0.5 mL /kg/hour. Urine electrolyte composition, osmolality, and specific gravity aid in the differential diagnosis of oliguria Urinary bladder catheterization is the only reliable method of monitoring urine output. Bladder catheterization should be avoided in patients at high risk for infection Catheterization is indicated: - In patients with congestive heart failure, renal failure, advanced hepatic disease, or shock. - Routinely in cardiac surgery, aortic or renal vascular surgery, craniotomy, major abdominal surgery, or procedures in which large fluid shifts are expected. - Postoperative bladder catheterization is indicated in patients having difficulty voiding in the recovery room after general or regional anesthesia. Complications of catheterization include: - urethral trauma and urinary tract infections. - Rapid decompression of a distended bladder can cause hypotension. 4-ABG and Electrolytes Monitoring. BLOOD SAMPLES These must be drawn from an artery into a glass syringe whose dead space has been filled with heparin. Samples should therefore be analyzed at once, or kept cool to reduce 02 consumption. 5-Monitoring during transfer of patients This reflect the severity of the patient's condition, - The patients are stabilized before transfer.
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Specially designed trolleys , and framed units which fit on standard beds, to display parameters and prevent damage' to expensive equipment. - Battery power is necessary . Special problems exist in helicopters due to vibration and noise, and even the most elementary measurements may be impossible. . 6-Monitoring of blood loss 1-Gravimetric method -Blood loss is estimated by measurement of the gain in weight of swabs and towels, together with measurement of the contents of suction bottles; 1 ml of blood weighs 1g. 2-Colorimetric method -Swabs and towels are mixed thoroughly with a large known volume of fluid, which is then estimated clorimetrically. -The patient's haemoglobin must be known. Blood loss (ml) = Colorimeter reading x volume of solution (ml) 200 x patient's Hb (g%) Limitations of monitors Occasionally clinical signs and subjective feelings are better than electronic monitoring, Electronic monitoring may not necessarily detect an abnormality until relatively late when the initial compensation by the body in the face of overwhelming physiological insult is eventually lost. Example: Postoperative hemorrhage, where vascular parameters may be maintained up to the final collapse, but the feel of the peripheral pulse, the colour of the patient's skin and the nature of the patient's pain give much earlier warning;

Afrah Babli 2022040033

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