MONITORING DURING ANESTHESIA

BY DOCTOR NASRULLAH KHAN MBBS FCPS

INTRODUCTION
In modern anesthesia very potent drugs are being used and awareness of patients about their care has put the patient and anesthetist at risk of various complications therefore monitoring has become an essential aspect of anesthesia care. The effective monitoring reduces the potential for poor outcomes that may follow anesthesia by identifying derangements before they result in serious or irreversible injury. Electronic monitors also improve physician's ability to respond because he or she is able to make repetitive measurements at higher frequencies than humans and do not fatigue or become distracted. Monitoring devices potentially increase the specificity and precision of clinical judgments.

STANDARDS OF MONITORING
Two standards for basic anesthetic monitoring have been established by the American Society of Anesthesiologists (ASA) in 1986 and reaffirmed on October 25, 2005. These standards have emphasized the evolution of technology ,practice, clinical judgment and experience .

 These standards apply to all anesthesia care, (general anesthesia, regional anesthesia and monitored anesthesia care) No anesthetic procedure should be started without strictly observing these standards prior to operation, except in emergency circumstances, where appropriate life support measures take precedence.

STANDARD 1

Standard I requires qualified personnel to be present in the operating room during general anesthesia, regional anesthesia, and monitored anesthesia care to monitor the patient continuously and modify anesthesia care based on clinical observations and the responses of the patient to dynamic changes resulting from surgery or drug therapy.

STANDARD 2 Standard II focuses attention on continually evaluating the patient's oxygenation, ventilation, circulation, and temperature and specifically mandates to monitor the following Pulse , Oxygen saturation (Pulse oximetry) Blood Pressure (Non-invasive), ECG, EtCO2(Capnography)

However in complicated cases more extensive monitoring may be required. Blood pressure (Invasive), Central venous pressure, Cardiac output Pulmonary artery pressure. Temperature. Renal functions Muscle relaxation Depth of anesthesia

1.PULSE OXIMETRY
Pulse oximetry is a technique which measure pulse and oxygen saturation non invasively. It combines the principles of oximetry and plethysmography . A sensor containing light sources (two or three lightemitting diodes) and a light detector (a photodiode) is placed across a finger, toe, earlobe, or any other perfused tissue that can be transilluminated.

 Oximetry depends on the observation that oxygenated and reduced hemoglobin differ in their absorption of red and infrared light (LambertBeer law). Oxyhemoglobin (HbO2) absorbs more infrared light (960 nm), whereas deoxyhemoglobin absorbs more red light (660 nm) which is analyzed by spectrophotometry.

 Pulse oximeters are mandatory for almost all types of anesthetics including even moderate sedation. These are particularly useful in children and in compromised patient having lung disease or cardiac problems. The nature of the surgical procedure (chest surgery) ,or special anesthetic technique (e g, one-lung anesthesia) also make it very essential.

 ALTOUGH OXIMETRY HELPS IN FINDING PROBLEMS WITH O2 SUPPLY ,CONDITION OF LUNGS, O2 CARRYING CAPACITY OF BLOOD AND

but does not give exact information about adequate ventilation so that the severe hypercarbia can develop without any alarm. CarboxyHb ,Met Hb ,hypotension, discoloration of nails, skin pigmentation and anemia can interfere with actual reading.
PERFUSION OF TISSUES

2.CAPNOGRAPHY
Capnography is measurement of end-tidal CO2 (ETCO2) which rely on the absorption of infrared light by CO2. As we know that CO2 is produced at cellular level when carbohydrates combine with O2 and then is carried out by the blood to lungs ,from where it is excreted by ventilation. Therefore capnography gives not only the information about adequate ventilation but also about all the mechanism involved in production and excretion of CO2.

 The various pattern of capnography gives lot of information about the different complication of anesthesia or surgical procedure. Although ,Ventilation can be monitored by observing the rate of respiration, pattern of breathing and auscultation of the breath sounds but capnogrphy has no match.. A rapid fall of ETCO2 is a sensitive indicator of air embolism, which is a major complication of sitting craniotomies. There is no contraindication.

Examples of capnograph waves

A, Normal spontaneous breathing.

B, Normal mechanical ventilation.

Examples of capnograph waves

G, Exhausted CO2 absorbent produces an inhaled CO2 concentration greater than zero.

Examples of capnograph waves

H, Double peak for a patient with a single lung transplant.

CAPNOGRAPHY VS OXIMETRY

OXYGEN AIR ---------LUNGS------BLOOD------TISSUES(CELLS) DETECTED BY OXYGEN PROBE CARBON DIOXIDE

TISSUE(CELL)------BLOOD------LUNGS------AIRWAYS (O2+CHO) DETECTED BY CO2 SENSOR

3.ELECTROCARDIOGRAPHY
Electrocardiography (ECG) should be started in all patients undergoing surgery before induction of anesthesia. This gives lot of information about heart rate, rhythm, ischemic changes, and conduction defects in heart. There is no contraindication.

SOME COMMON ECG TRACINGS

Sinus normal rhthym Sinus tachycardia

Sinus bradycardia

 Atrial flutter

Atrial fibrillation

Ventricular tachycardia
PVCs

 Ventricular fibrillation

Ventricular asystole

4.BLOOD PRESSURE
Non invasive Blood Pressure Monitoring The use of any anesthetic, no matter how "trivial," is an absolute indication for arterial blood pressure measurement. The techniques and frequency of pressure determination depend on the patient's condition and the type of surgical procedure. An oscillometric blood pressure measurement every 35 min is adequate in most cases.

 Invasive Blood Pressure Monitoring Arterial-Line is Indicated for invasive arterial blood pressure monitoring for following purposes, 1. Induced hypotension, 2. Anticipation of wide blood pressure swings, 3.End-organ disease necessitating precise beat-to-beat blood pressure regulation, and the need for multiple arterial blood gas analyses.

5.Central venous pressure

Central venous pressure is measured to see the status of body fluids and cardiac capability to maintain circulation. The central venous catheter is passed for monitoring of 1. Central venous pressure (CVP), 2. Administration of fluid to treat hypovolumia and shock, 3. Aspiration of air emboli, If these occur during surgery. 4. Gaining venous access in patients with poor peripheral veins.

Contraindications

1. Renal cell tumor extending into the right atrium 2. Fungating tricuspid valve vegetations. 3. Receiving anticoagulants 4. who have had an ipsilateral carotid endarterectomy, because of the possibility of unintentional carotid artery puncture.

6.Pulmonary artery catheterization

Although the effectiveness of pulmonary artery catheter (PAC) monitoring remains largely unproven in many groups of surgical patients, the ASA concludes that the appropriateness of PAC use depends on the combination of risks associated with the patient, the operation, and the setting ,therefore it is indicated in cardiac surgery only.

7.Temperature
Temperature of every patient undergoing general anesthesia /spinal anesthesia should be monitored except very brief procedures (eg, less than 15 min). Esophageal probe or skin probe can be used for this purpose.

8.Urine output
Insertion of a urinary catheter is indicated in patients with 1. congestive heart failure, 2. renal failure, 3. advanced hepatic disease, 4. shock. 5. Prolonged surgery 6. Spinal anesthesia

Catheterization is routine in some surgical procedures such as

1. Cardiac surgery, 2. Aortic or renal vascular surgery, craniotomy, major abdominal surgery, or procedures in which large fluid shifts are expected.
3. Requiring intra operative diuretic administration 4. Patients having difficulty in passing urine in recovery room after general or regional anesthesia.

9.Peripheral nerve stimulator

Muscle are paralyzed during anesthesia for various surgical cases. Muscle relaxation is required to be monitored with help of nerve stimulator because of the variation in patient sensitivity to neuromuscular blocking agents, and the nature of surgery. Especially during neurosurgery and eye surgery where accurate level of relaxation is mandatory all the time throughout procedure.

 Nerve stimulator is also used in assessing paralysis during rapid-sequence induction or during continuous infusions of short-acting muscle relaxants . To locate nerves to be blocked by regional anesthesia. To diagnose type and degree of muscle block during prolonged apnea

10.Bi spectral index scale

Now a days awareness during anesthesia has become a challenging problem for the anesthetist especially in emergency cases when patient is not completely fit for anesthesia and therefore relatively light anesthesia is indicated .In such situation it becomes mandatory to assess the exact level of depth of anesthesia. For this purpose various methods were used but without rewarding results. Recently a new method of assessing depth of anesthesia during operation has been introduced which has encouraging result. It is an advanced form of electroencephalography and is known as BI SPECTRAL INDEX SCALE (B . I .S).

To perform a bi-spectral analysis, data measured by EEG are taken through a number of steps to calculate a single number that correlates with depth of anesthesia / hypnosis. BIS values of 6585 have been advocated as a measure of sedation, 4065 have been recommended for general anesthesia

I___I___I___I___I___I___I___I__ I 100 90 80 70 60 50 40 30 20
AWAKE SEDATION ANESTHESIA CORTICAL SILENCE

 The use of Bispectral analysis may help in reducing the chances of awareness during anesthesia, an issue that is important to the public. It may also reduce resource utilization because less drug is required to ensure amnesia, facilitating a faster wake-up time and perhaps a shorter stay in the recovery room.
But unfortunately it is effective only in conventional form of general anesthesia and not in Ketamine anesthesia.

11.Measurement of anesthetic agent concentraion

Concentration of anesthetic agent in the end tidal air is also measured to assess the level of anesthesia depth and to avoid the dangerous side effects of strong volatile anesthetic agents.

12.Blood chemistry
Blood samples are sent to laboratory for measurement of Hb % to assess blood loss during surgery. Arterial blood gases and electrolytes are measured to find out acid base disorders and electrolyte disturbances during operation.

CONCLUSION
Monitoring during anesthesia has revolutionized field of anesthesia and use of very potent drugs has become possible without serious complications. Human brain has no substitute therefore presence of qualified person has been put as standard 1 of monitoring.