minimum mandatory monitoring during anaesthesia kalyani hospital

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mandatory monitoring during anaesthesia dr deepak nirwal kalyani hospital kiratpur bijnor up

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Presented By :-Dr. Deepak Nirwal Guided By:- Dr. R. Subhedar sir and Dr. S. Thorat sir Dept of Anaesthesia GMC , Dhule MINIMUM - MANDATORY MONITORING guidelines 4/3/2014 1:43 PM 1

Contents :

Contents 4/3/2014 1:43 PM 2

INTRODUCTION :

INTRODUCTION The practice of Anaesthesiology is among the most potentially dangerous disciplines of medicine both for the patient and the practitioner. There are no strategies that can guarantee that the anaesthesiologist can prevent a bad outcome. However there are strategies that enable the anaesthesiologist to minimize the chances of a bad outcome and know what to do if one should occur. 4/3/2014 1:43 PM 3

Intraoperative monitoring:

Intraoperative monitoring The most primitive method of monitoring the patient 25 years ago was continuous palpation of the radial pulsations throughout the operation!! 4/3/2014 1:43 PM 4

Substitute for multipara monitor :

Substitute for multipara monitor 4/3/2014 1:43 PM 5

Objective of clinical monitoring :

Objective of clinical monitoring To understand & appreciate the value of clinical monitoring. RULE : our clinical judgement/assessment is much BETTER & much more VALUABLE than the digital monitor. To appreciate that modern monitors have made life much easier for us. They are present to make monitoring easier for us NOT to be omitted or ignored. 4/3/2014 1:43 PM 6

Intraoperative monitoring: Introduction:

Intraoperative monitoring : Introduction Why do we need intraoperative monitoring??? To maintain the normal pt physiology & homeostasis throughout anesthesia and surgery- To ensure the well being of the pt. Surgery is a very stressful condition → severe sympathetic stimulation and autonomic changes Most drugs used for general & regional anesthesia cause hemodynamic instability, myocardial depression. Under GA the pt may be hypo or hyperventilated and may develop hypothermia . Blood loss → anaemia, hypotension. So it is necessary to recognise when the pt is in need of blood transfusion (transfusion point) . 4/3/2014 1:43 PM 7

PowerPoint Presentation:

The primary goal of anesthesia is to keep the patient as safe as possible in the perioperative period . Continuous monitoring of the patient during and after surgery allows the clinician to identify problems early, when they can still be corrected. Basic Goal of Anesthetic Monitoring 4/3/2014 1:43 PM 8

PowerPoint Presentation:

‘ Guidelines ’ specify what is usually expected , while ‘ standards ’ specify what is always expected . The current standards anesthesia monitoring are published & most recently updated in 2011 by ASA. Failure to follow nationally published standards puts the provider at risk for credentialing problems and lawsuits. Standards of Care 4/3/2014 1:43 PM 9

ASA- guidelines :

ASA- guidelines Standards Standard 1:  Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care Standard 2:  During all anesthetics, the patient's oxygenation, ventilation, circulation, and temperature shall be continually* evaluated Guidelines Oxygenation: Oxygen analyzer for inspired gases Observation of the patient Pulse oximetry Ventilation: Auscultation of breath sounds Observation of the patient / reservoir bag Capnography (Carbon dioxide monitoring) Circulation: Continuous* ECG display Heart rate and BP recorded every 5 minutes Auscultation of heart sounds Palpation of pulse Pulse oximetry /plethysmography Intraarterial pressure tracing Temperature: Monitor temperature when changes are intended, anticipated, or suspected 4/3/2014 1:43 PM 10

ISA –Standards & Guidelines :

ISA –Standards & Guidelines 4/3/2014 1:43 PM 11

ISA – monitoring guidelines introduction:

ISA – monitoring guidelines introduction Administration of anaesthesia asso with risk and complication (related to drugs , technique , asso medical and surgical disease ) Morbidity & mortality due to anesthesia may not be entirely predictable or preventable. But continuous monitoring can minimized bad outcome. Adoption of good and proper monitoring standards in clinical anesthetic practice has considerably improved the patient safety and outcome. “Eternal Vigilance” is the motto of ASA . The same has been accepted and practiced ISA . 4/3/2014 1:43 PM 12

ITF ( WFSA ) :

ITF ( WFSA ) The wide acceptance of monitors in anesthetic safety resulted in formation of a task force under World Federation of Anesthesiologists in 1989. Why ITF was constituted :-??????? Guidance and assistance to anesthetic /hospital administrators/governments in improving the quality and safety of anesthesia Update and improve minimum mandatory monitory standards as applicable to each country, depending on the medico-legal . The recommendations of ITF were accepted by WFSA in 1992. The ISA took guidelines from Recommendations of WFSA for “Monitoring standards & were introduced and adopted by ISA in 1999 , and these were updated in march 2010 and publish 2011 , Recent guidelines in view of much changes in practice of anesthesia all over the country and availability of low cost monitors , which can be procured even by smaller hospitals. . 4/3/2014 1:43 PM 13

India a country of diversity :

India a country of diversity ISA standards has made the hospital management to realize the need for procurement of new monitors. The Consumer Protection Act (CPA) has indirectly made the management follow these guidelines seriously. Keeping these in view, new monitoring standards has been revised to allow safe practice of anesthesia in all types of hospitals. 4/3/2014 1:43 PM 14

Section – 1 , The Anesthesiologist:

Section – 1 , The Anesthesiologist Who can administer anaesthesia ?? A qualified Anaesthesiologist ( MD/DA/DNB) , who is well aware of problems and solutions shall provide anesthesia to the patient. The practice by Surgeon himself /nurse /technician should strongly discouraged in interest of patient outcome. The hospital management shall be responsible for employing or providing a qualified Anaesthesiologist for the surgery i.v.o providing anesthesia in their hospital. Its the responsibility of hospital management to provide a PG trainee/ nurse / anesthesia technician / trained paramedical person immediately an assistant to the Anaesthesiologist for help . 4/3/2014 1:43 PM 15

Section – 1 , The Anesthesiologist:

Section – 1 , The Anesthesiologist The Anaesthesiologist shall be present throughout the surgical procedure and shift and for hand over the patient to respective area -ward / ICU /HDU, in view of rapid changes in pt condition . During surgery a temporary absence of the primary Anaesthesiologist he should handover the pt to either another anaesthetic / trainee / trained assistant . The Anaesthesiologist should maintain the same level of monitoring irrespective of type of anesthesia , Though utmost care is given while patient is receiving general anesthesia, there should not be any laxity in care during regional or monitored anesthesia care . The Anaesthesiologist should maintain & record the monitored data at intervals not longer than five minutes in rapidly changing situations and not longer 10 minutes in stable patients. 4/3/2014 1:43 PM 16

Section II: Monitors and Monitoring the Patient:

Section II: Monitors and Monitoring the Patient During anesthesia, it is mandatory for all patients to be monitored for Oxygenation, Ventilation, and Circulation both clinically and with appropriate monitors. It is mandatory to monitor oxygenation of every anesthetized patient:- Clinically by colour of the skin and mucous membrane and operating field. So adequate illumination required in OT . and pulse oximeter with working alarm for SpO2 ,PR & plethysmography strongly recommended. It is mandatory for all patients to receive an assured Inspired Oxygen concentration of at least 25%. So Anesthetic machine, has incorporated a antihypoxic alarm system (audiovisual) 4/3/2014 1:43 PM 17

Section II cont……:

Section II cont…… It is mandatory to monitor ventilation of every anesthetized patient:- Clinically by chest / bag movement , stethoscope . Capnography Monitoring of Expired tidal or MV of the patient in some surgery. It is mandatory to check the position of ET tube or LMA . it is mandatory that there should be an alarm system to detect disconnection of the patient from mechanical ventilation. 4/3/2014 1:43 PM 18

Section II cont……:

Section II cont…… It is mandatory to monitor Circulation of every anesthetized patient Clinically by palpation of pulse . It is mandatory to monitor the cardiac function by continuous ECG It is mandatory to monitor the blood pressure frequently i.e. not longer than five minutes .NIBP (manual / automated ) Invasive BP and CVP monitoring is recommended in select situations e-g . major CTVS, surgery where rapid hemodynamic changes. 4/3/2014 1:43 PM 19

Section III: Additional Monitoring Recommendations:

Section III: Additional Monitoring Recommendations Patients belonging to High risk category / Pediatric / Geriatric/Requiring large volume replacements may be monitored with temperature monitors . The core body temperature could be monitored with nasopharyngeal or oesophageal or rectal probes . Warming devices should be used as and when the need arises. Neuromuscular monitoring may be used in select situations & surgeries e.g. neuromuscular diseases, requirement of large doses of relaxants, delayed recovery 4/3/2014 1:43 PM 20

Section IV: Monitoring the Equipment:

Section IV: Monitoring the Equipment The hospital management shall be responsible for procurement, maintenance servicing & calibration of monitor and other anesthetic equipments. They should procure the equipments in adequate numbers. The concerned Anaesthesiologist shall be familiar with the setup, proper use , before connecting them to the patient Anaesthesiologist should check all the anesthetic equipments , monitors ,and set their alarm parameters. In children and other uncooperative patients who are not accepting the monitors in a conscious state, anesthesia could be induced with clinical monitoring of Pulse, BP and auscultation. Monitors could be connected ASAP. 4/3/2014 1:43 PM 21

Section V: Monitoring during Transportation to POCU:

Section V: Monitoring during Transportation to POCU All patients shall be monitored continuously till he recovers from anesthesia and has intact reflexes. Patients are to be transported to the post-operative recovery area by the Anaesthesiologist / Assistant and the patient is handed over to the ward in charge. The summary of the anesthesia record and necessary postoperative instructions are to be handed over. Patient should be under continuous observation with ECG, Pulse Oximeter and BP monitoring as needed. 4/3/2014 1:43 PM 22

Section VI: Monitoring in the PACU:

Section VI: Monitoring in the PACU The patient shall be monitored in the Post-operative recovery area with continuous monitoring of ECG, Pulse Oximeter and BP. A PACU monitoring chart shall be maintained and document T , P , R , BP , I/O , level of consciousness charting @ every 15 min & earlier if pt deteriorates . Patient shall be transferred to ward from PACU, when patient completely recovered from effect of anaesthesia . If pt condition unstable than shift pt to ICU/HDU . For further management . 4/3/2014 1:43 PM 23

Medical professional under CPA law :

Medical professional under CPA law 4/3/2014 1:43 PM 24 Anaesthesia practice is neither insulated nor immunized against medical jurisprudence.

Regular use of monitors :

Regular use of monitors Today on one hand we have modern anaesthesia and sophisticated monitoring gadgets but on other hand there are still some places in our country where anaesthetic is expected to work with a bottle of ether and use both hands for monitoring the pulse and BP. After SC verdict , the general public become euphoric and feel relieved that doctors are accountable and come under the purview of consumer protection Act (CPA ). But because of CPA ( thought like “swords of Damocles “hanging over our head ) made many of us more ethical , more vigilant and has initiated us to demand the monitoring equipment from hospital authorities ,not only for pt safety but for our personal safety as well. Now, no anaesthesiologists in India likes to take the risk of practicing without minimum mandatory monitoring for anaesthesia. 4/3/2014 1:43 PM 25

Believe your monitors :

Believe your monitors Don’t find fault with the monitor , but try to find something wrong with patient . Although majority of time it’s the monitor , but the consequences of assuming this all the time like to invite bad & irreversible outcome . With use of multiple monitors such as ECG, pulse oximetry, capnography, BP and the precordial stethoscope we can cross check each other . Anaesthesiologists must learn to rule out the patient problem as the first thought and then consider a problem with the monitor. The safest rule is to believe your monitors and assume that any monitor dysfunction is a patient problem 4/3/2014 1:43 PM 26

Mortality and monitoring :

Mortality and monitoring Cohort study data :- in a cohort of patients (n=869483) who underwent general, regional or combined anaesthesia to determine the relationship of perioperative mortality with anaesthesia. For every 10,000 anaesthetic 24 hr perioperative mortality was 8.8 (95% Cl,- 8.2-9.5), of perioperative coma was 0.5 (0.3 -0.6) and of anaesthesia related death 1.4 (1.1-1.6). In anaesthesia related death (52%) were associated with ‘CV management, (48%) with other anaesthetic management, (10%) with Ventilatory management. (10%) with patient monitoring. Indian J. Anaesth, 2002; 46 (4): 244-245 4/3/2014 1:43 PM 27

Hurdles in monitoring :

Hurdles in monitoring The single most imp. hurdle for the improvisation of our health care system is the expensive cost of care, and the costs continue to rise, most importantly increased costs have not been associated with improved outcome Cost benefit analysis of monitoring:- In a closed claim analysis, it was found that 80% of the preventable outcomes were associated with respiratory system incidents. A pulse oximeter, capnograph or a combination of both would have prevented the adverse outcome in 93% of cases Costs of monitoring include cost of the anaesthesiologist, monitors, consumable items, operating room time, maintenance costs and the cost of complications 4/3/2014 1:43 PM 28

Basic Intraoperative monitoring:

Basic Intraoperative monitoring The FOUR BASIC Monitors : We are NOT authorised to start a surgery in the absence of any of these monitors: ECG. SpO2: arterial O2 saturation. Blood Pressure: NIBP (non-invasive), IBP (invasive). ± [Capnography]. The most critical 2 times during anesthesia are: INDUCTION - RECOVERY. Exactly like “ flying a plane ” induction (= take off) & recovery (= landing). The aim is to achieve a smooth induction & a smooth recovery & a smooth intraoperative course. 4/3/2014 1:43 PM 29

(1) ECG:

(1) ECG 4/3/2014 1:43 PM 30

Intraoperative monitoring: (1) ECG:

Intraoperative monitoring : (1) ECG Value : Heart rate. Rhythm (arrhythmias) usually best identified from lead II ,V5. Ischemic changes & ST segment analysis. Timing of ECG monitoring : Throughout the surgery: before induction until after extubation & recovery. Types & connections of ECG cables : 3-leads : R ed= R ight Ye LL ow = L eft B lack=A p ex (can read leads: I, II, III) 5-leads : R ed= R ight Ye LL ow = L eft Black=under red Green=under yellow White/brown =central (can read any of the 12 leads: I, II, III, avR, avL, avF, V1-V6). 4/3/2014 1:43 PM 31

PowerPoint Presentation:

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PowerPoint Presentation:

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Intraoperative monitoring: (1) ECG:

Intraoperative monitoring : (1) ECG How to attach ECG electrodes: Choose a bony prominence . Avoid fatty regions AVOID hairy areas (up to shaving if required in very hairy persons). Position them far away from each other to give e higher voltage and better gain. Ensure good contact with the skin: by using KY-Gel. The electrodes will not be accessible during the surgery 4/3/2014 1:43 PM 34

Intraoperative monitoring: (1) ECG:

Intraoperative monitoring : (1) ECG If the EGC gives no trace (noise): follow ECG cable from the pt to the monitor: Ensure good contact with the pt: non-hairy areas, apply KY-Gel, search for slipped or loose electrodes. Ensure proper fitting of cable connections. (Sometimes we apply alcohol to dissolve betadine). Ensure proper fitting of the cable to the monitor. Change monitor settings: try different leads (I, II, III, avR, avR, avL, V1-6), filter, size (amplitude) of ECG. 4/3/2014 1:43 PM 35

Intraoperative monitoring: (1) ECG:

Intraoperative monitoring : (1) ECG RULES : QRS beep ON must be heard at all times. NO silent monitors. Remember that your clinical judgement is much more superior to the monitor. Check peripheral pulsations. Cautery → artefacts & fallacies in ECG (noise/ electrical interference) → check radial (peripheral) pulsations to rule out arrhythmias 4/3/2014 1:43 PM 36

(2) SpO2:

(2) SpO 2 4/3/2014 1:43 PM 37

Intraoperative monitoring: (2) SpO2:

Intraoperative monitoring : (2) SpO2 It is the most important monitor . It gives a LOT of information about the pt. Definition : % of oxy-Hb / oxy + deoxy-Hb. Timing of SpO2 monitoring: throughout the surgery: before induction till after extubation & recovery. It is the LAST monitor to be removed off the pt before the pt is transferred outside the operating room to recovery room. SpO2 monitoring should be continued in recovery room. Waveform of pulse oximeter = plethysmography (arterial waveform). It indicates that the pulse oximeter is reading the arterial O2 saturation. Without the waveform pulse oximeter readings are unreliable & incorrect. 4/3/2014 1:43 PM 38

Intraoperative monitoring: (2) SpO2:

Intraoperative monitoring : (2) SpO2 Value : SpO2 : arterial O2 saturation (oxygenation of the pt). HR. Peripheral perfusion status (loss of waveform in hypoperfusion states: hypotension & cold extremeties). Gives an idea about the rhythm from the plethysmography wave (arterial waveform). (Cannot identify the type of arrhythmia but can recognize if irregularity is present). Cardiac arrest. Pulse oximeter tone changes with desaturation from high pitched to low pitched (deep sound). So just by listening to the monitor you can recognize: (1) HR (2) O2 saturation. 4/3/2014 1:43 PM 39

Intraoperative monitoring: (2) SpO2:

Intraoperative monitoring : (2) SpO2 How to attach/apply saturation probe: To the finger or toe (if finger is not accessible). The red light is applied to the nail. Nail polish and stains should be removed → false readings and artefacts. Can also be applied to the ear lobe . In infants and children can be applied to 2 fingers or to the hand. Usually attached to the limb with the IV line (opposite the limb with the blood pressure cuff). 4/3/2014 1:43 PM 40

PowerPoint Presentation:

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Intraoperative monitoring: (2) SpO2:

Intraoperative monitoring : (2) SpO2 Readings : Normal person on room air (O2 = 21%) ˃ 96%. Patient under GA (100% O2) = 98-100%. It is not accepted for O2 saturation to ↓ below 96% with 100% O2 under GA. Must search for a cause. < 90% = hypoxemia. < 85% = severe hypoxemia. 4/3/2014 1:43 PM 42

Intraoperative monitoring: (2) SpO2:

Intraoperative monitoring : (2) SpO2 Fallacies & Inaccuracies occur when: Misplaced on the pts finger, slipped. Pt movement, shivering. Poor tissue perfusion (cold extremities) → warm the pt by any means (always avoid hypothermia). Poor tissue perfusion (hypotension & shock). Cardiac arrest. Sometimes by electrical interference from cautery in some monitors. 4/3/2014 1:43 PM 43

Intraoperative monitoring: (2) SpO2:

Intraoperative monitoring : (2) SpO2 RULES: Keep the sound of the pulse oximeter ON at ALL times. Pay attention to the sound of the pulse oximeter. NO silent monitors. ALWAYS Remember that your clinical judgement is much more superior to the monitor. Check pt colour for cyanosis: lips, nails. If hypoxemia occurs immediately check the correct position of the probe on the pt and check the pts colour : nails & lips, then manage accordingly & CALL 4 HELP . 4/3/2014 1:43 PM 44

(3) Blood Pressure:

(3) Blood Pressure 4/3/2014 1:43 PM 45

Intraoperative monitoring: (3) BP:

Intraoperative monitoring : (3) BP NIBP : provide SBP,DBP and with automated MAP Value : to avoid and manage extremes of hypotension & HTN. Avoid ↓ MAP < 60 mmHg (for cerebral & renal perfusion) & avoid ↓ diastolic pressure < 50 mmHg (for coronary perfusion). HTN episodes: → (CVS): myocardial ischemia, pulmonary edema, (CNS): hemorrhagic stroke, hypertensive encephalopathy. Hypotensive episodes: → (CVS): myocardial ischemia, (CNS): ischemic stroke, hypoperfusion state metabolic acidosis, delayed recovery, renal shutdown. 4/3/2014 1:43 PM 46

Intraoperative monitoring: (3) BP:

Intraoperative monitoring : (3) BP Timing of BP monitoring : throughout the surgery: before induction till after extubation & recovery. Frequency of measurement : By default every 5 minutes. Every 3 minutes: immediately after spinal anesthesia, in conditions of hemodynamic instability, during hypotensive anesthesia. Every 10 minutes: eg. In awake pts under local anesthesia: “monitored anesthesia care” (minimal hemodynamic changes). 4/3/2014 1:43 PM 47

Intraoperative monitoring: (3) BP:

Intraoperative monitoring : (3) BP How to attach/apply : Correct cuff size : width of the cuff should be 1.5 times limb diameter and should occupy at least 2/3 of the arm. 2 cuff sizes for adult: blue : for most adult individuals (60-90 Kg), red : for morbid obese. Selection of appropriate cuff size is important because a ti gh t cuff leads to false hi gh readings, while a L oose cuff gives false L ow readings. 4/3/2014 1:43 PM 48

PowerPoint Presentation:

Is better applied directly to the arm (remove sleeve). May also be applied to the forearm in very obese individuals. May be applied to the calf if the arms are not accessible during surgery. Correct positioning : cuff is positioned with the hoses over the brachial artery . Usually attached to the limb opposite the IV line & pulse oximeter. Unless the pt is performing hand or arm or breast surgery, the BP cuff is attached with the IV line and saturation probe on the same side. AVOID attaching it to an arm with A-V graft (for renal dialysis) → damage of AV graft, & inaccurate measurements. 4/3/2014 1:43 PM 49

Intraoperative monitoring: (3) BP:

Intraoperative monitoring : (3) BP Reading Error/failure : Pressure line is disconnected. Leakage from damaged cuff. Line is compressed (under someone’s foot or under a weal). Line contains water from washing! Monitor error: cuff cannot inflate due to infant or neonate limits. 4/3/2014 1:43 PM 50

Intraoperative monitoring: (3) BP:

Intraoperative monitoring : (3) BP RULE : YOUR clinical judgement is always superior to the monitor. Must check peripheral pulse volume from time to time (Radial A, or Dorsalis Pedis A, or Superficial Temporal A) regularly every 10 minutes. Check pt colour for pallor : lips, tongue, nails, conjunctiva. 4/3/2014 1:43 PM 51

Intraoperative monitoring: (3) BP:

Intraoperative monitoring : (3) BP IBP : (invasive arterial blood pressure monitoring) It is beat to beat monitoring of ABP via an arterial canula. Indicated in: major surgeries, during deliberate hypotensive anesthesia, during the use of inotrops , cardiac surgery, in surgeries involving extreme hemodynamic changes/instability eg. pheochromocytoma, repeated ABG sampling. 4/3/2014 1:43 PM 52

(4) Capnography (CO2):

(4) Capnography (CO2) 4/3/2014 1:43 PM 53

Intraoperative monitoring: (4) CO2:

Intraoperative monitoring : (4) CO2 Definition : What is Capnography? Continuous CO2 measurement displayed as a waveform sampled from the patient’s airway during ventilation. What is EtCO2? A point on the capnogram. It is the final measurement at the endpoint of the pts expiration before inspiration begins again. It is usually the highest CO2 measurement during ventilation. 4/3/2014 1:43 PM 54

Intraoperative monitoring: (4) CO2:

Intraoperative monitoring : (4) CO2 Phases of the capnogram: Baseline: A-B Upstroke: B-C Plateau: C-D End-tidal: point D Downstroke 4/3/2014 1:43 PM 55

Intraoperative monitoring: (4) CO2:

Intraoperative monitoring : (4) CO2 Normal range : 30-35 mmHg . (Usually lower than arterial PaCO2 by 5-6 mmHg due to dilution by dead space ventilation). Value (data gained from capnography & ETCO2): ETT : esophageal intubation. Ventilation : hypo & hyperventilation, curare cleft (spontaneous breathing trials). Pulmonary perfusion : pulmonary embolism . Breathing circuit : disconnection, kink, leakage, obstruction, unidirectional valve dysfunction, rebreathing, exhausted soda lime. Cardiac arrest : adequacy of resuscitation during cardiac arrest, and prognostic value (outcome after cardiac arrest). 4/3/2014 1:43 PM 56

Intraoperative monitoring: (4) CO2:

Intraoperative monitoring : (4) CO2 Factors affecting EtCO2: what ↑ what ↓ EtCO2? 4/3/2014 1:43 PM 57

Individual System Monitoring:

Individual System Monitoring Position of ETT. Respiratory System. CVS & Hemodynamic Monitoring. CNS: Awareness. Temperature. Monitoring after Extubation & Recovery. 4/3/2014 1:43 PM 58

(A) Correct Position of ETT:

(A) Correct Position of ETT 4/3/2014 1:43 PM 59

Correct Position of ETT:

Correct Position of ETT After intubation Auscultation MUST be done in 5 areas: ► Rt & Lt Infraclavicular. ► Rt & Lt axillary. ► EPIGASTRIUM: to exclude esophageal intubation. We MUST ALWAYS auscultate the chest after intubation for: (1 ) Equal air entry : to exclude endobronchial intubation. (2 ) Adventitious sounds : wheezes, crepitations, pulmonary edema. We MUST ALWAYS auscultate the chest AGAIN after repositioning to exclude: Inward displacement → endobronchial intubation. Outward displacement → slippage & accidental extubation. 4/3/2014 1:43 PM 60

Respiratory Monitoring:

Respiratory Monitoring Clinical monitoring : Colour: cyanosis : nails, lips, palms, conjunctiva. Chest rise & fall ( inflation ). Vapour in ETT (absent in ventilators with humidifiers/if filter is used). Airway pressure . Ventilator bellows (return to full inflation during expiratory phase). Ventilator sound : during resp cycle. Abnormal sounds eg. leakage, disconnection, high airway pressure, alarms. 4/3/2014 1:43 PM 61

Respiratory Monitoring:

Respiratory Monitoring NEVER ignore an alarm by the ventilator! Low airway pressure : leakage, disconnection. High airway pressure : kink, biting of the tube, bronchospasm, slipped → esophagus. Low expired tidal volume : leakage. Apnea alarm : disconnection. O2 sensor failure : Flow sensor failure : 4/3/2014 1:43 PM 62

Respiratory Monitoring:

Respiratory Monitoring Respiratory Monitors : O2 Saturation. Capnography EtCO2. Airway pressure. ABG samples. 4/3/2014 1:43 PM 63

CVS Hemodynamic Monitoring :

CVS Hemodynamic Monitoring Clinical monitoring : Colour : pallor (lips, tongue, nails) = anaemia, shock. Palpate peripheral pulsations every 10 minutes (Radial A, Dorsalis pedis A, Superficial temporal A). Capillary refilling time : compress nail bed until it is blanched. After release of pressure refilling should occur within 2 seconds. If ˃ 5 seconds = poor peripheral perfusion/circulation. UOP : Values: it is an indicator of: 1) good hydration 2) good tissue (renal) perfusion Catheter Indications: 1) lengthy surgery ˃ 4 hrs 2) major surgery with major blood loss 3) C-section: to monitor injury to the bladder or ureter . Normal: 0.5-1 ml/kg/hr. always note the baseline urine volume at the start of operation. 4/3/2014 1:43 PM 64

CVS Hemodynamic Monitoring:

CVS Hemodynamic Monitoring Management of oliguria or anuria : Check that the catheter is not kinked /block/disconnected. Ask surgeon to Palpate the urinary bladder (suprapubic fullness) Raise BP (MAP ˃ 80 mmHg): renal perfusion. IV fluid challenge . Diuretics . N.B. Sometimes Trendelenburg position (head down) causes ↓ UOP. Reversal of this position results in immediate flow of urine. 4/3/2014 1:43 PM 65

CNS: Awareness:

CNS : Awareness Clinical monitoring : Signs of pt awareness: Movement, grimacing (facial expression). Pupils dilated. Lacrimation. Tachycardia. HTN. Sweating : is always an alarming/warning sign. Causes: Awareness. Hypoglycemia. Hypercapnia. Thyroid storm (thyrotoxic crisis). Fever. Always check the concentration of ur vaporizer & make sure that ur vaporizer is not empty , check dial conc. 4/3/2014 1:43 PM 66

Temperature Monitoring :

Temperature Monitoring Clinical monitoring : ur hands. Monitors : temperature probe: nasopharyngeal, esophageal . AVOID hypothermia < 36 o C . Why? & How? Especially in paediatrics & geriatrics (extremes of age). Why is it necessary to avoid hypothermia? (complications of hypothermia): Cardiac arrhythmias: VT & cardiac arrest. Myocardial depression. Delayed recovery (delays drug metabolism). Delayed enzymatic drug metabolism. Metabolic acidosis (tissue hypoperfusion → anerobic glycolysis → lactic acidosis) & hyperkalemia. Coagulopathy. 4/3/2014 1:43 PM 67

Temperature Monitors :

Temperature Monitors Lower esophageal temperature is normally a good reflection of core or blood temperature. Upper esophageal and nasopharyngeal temperature are affected by airway temperature, so are less accurate. Tympanic membrane temperature is also a good indication of core temperature but it is not practical in the surgical setting. Monitoring of skin temperature is nearly useless. 4/3/2014 1:43 PM 68

Temperature - Core Body Temperature:

Temperature - Core Body Temperature 4/3/2014 1:43 PM 69

Consequences of Hypothermia:

Consequences of Hypothermia Hemodynamic effects Coagulation Surgical wound infection Cardiac morbidity Metabolism of drugs Shivering 4/3/2014 1:43 PM 70

How to avoid hypothermia: :

How to avoid hypothermia : Warm IV fluids. Intermittently switching off air-conditioning esp. towards the end of surgery ( ↑ ambient room temp ). Paediatrics: warming blanket. 4/3/2014 1:43 PM 71

Monitoring After Extubation & Recovery :

Monitoring After Extubation & Recovery After extubation : immediately fit the face mask on the pt (with a slight chin lift) and observe the breathing bag: Good regular breathing with adequate tidal volume transmitted to the bag. No transmission to the bag → respiratory obstruction (improve ur support), or apnea (attempt to awaken ur pt by painful stimulus or jaw thrust). BP : within 20% of baseline. SpO2 : ˃ 92% Breathing : regular, adequate tidal volume. Muscle power : sustained head elevation for 5 seconds, good hand grip, tongue protrusion. Level of consciousness : fully conscious = 1) obeying orders, 2) eye opening, 3) purposeful movement. MOST IMP: Pt MUST be able to protect his own airway . 4/3/2014 1:43 PM 72

Normal target values for an adult under GA::

Normal target values for an adult under GA : HR : 60-90 (˃ 90 = tachycardia. < 60 = bradycardia). BP : 90/60 – 140/90. MAP ˃ 60 mmHg (cerebral & renal autoregulation). Diastolic BP ˃ 50 mmHg (coronary perfusion pressure). SpO2 ˃ 96% on 100% O2. EtCO2 = 30-35 mmHg. 4/3/2014 1:43 PM 73

LISTEN:

LISTEN Listen to the monitor the whole time : To the pulse oximeter tone to identify: 1-Heart rate 2- O2 saturation from the tone (pitch) of pulse oximeter. To the sound of the ventilator , to any abnormal sounds, any alarms. RULE : NO silent monitors. ALWAYS keep the HR sound on . If ur monitor is silent (sound is not working) u have to look at your monitor the WHOLE time. 4/3/2014 1:43 PM 74

XX NEVER XX:

XX NEVER XX 4/3/2014 1:43 PM 75

LööK:

L öö K Every 5 minutes to note the new BP reading. If there is any change in the tone of the pulse oximeter. If there is any irregularity in heart rate & during the use of diathermy. 4/3/2014 1:43 PM 76

Clinical Check / 10 minutes :

Clinical Check / 10 minutes 1) Chest inflation . 2) Ventilator bellows : descend and return to become fully inflated. 3) Airway pressure . 4) Palpate peripheral pulsations (radial A, or dorsalis pedis A, or superficial temporal A): For pulse volume. During the use of cautery. In doubt of ECG rhythm (arrhythmias). In case monitor or ECG disconnected. 5) Pt colour (nails): cyanosis, pallor. 6) Vaporizer : Check concentration opened. Level of the volatile agent (if needs to be filled). 4/3/2014 1:43 PM 77

RULES NEVER to FORGET::

RULES NEVER to FORGET: Never start induction with a missing monitor: ECG, BP, SpO2. Never remove any monitors before extubation & recovery. NEVER ignore an alarm by the ventilator. ALWAYS remember that ur clinical sense & judgement is better & superior to any monitor. The monitor is present to help us not to be ignored. Last but by no means least: ALWAYS remember that there is NO such thing as “ all monitors disconnected” → check that ur pt is ALIVE !! Immediately check peripheral & carotid pulsations to make sure that ur pt is not ARRESTED !! Once u have ensured pt safety reattach ur monitors once again. 4/3/2014 1:43 PM 78

Take home message :

Take home message 10 golden rule of anaesthesia :- A : -Assessment and preparation of patient N : -Nil per oral E : -Equipment and drugs checked S : -Suction working T : -Tipping table H : -Have a vein open E : -Evaluate vitals S : -Somebody to help I : -Intubation (Ventilation control) A : -Airway clear 4/3/2014 1:43 PM 79

PowerPoint Presentation:

4/3/2014 1:43 PM 80

References :

References 1. Cheney FW et al: Standard of Care and Anaesthesia liability: JAMA 1989:261:1599-1603. 2. F.A. Berry : What to do after a bad outcome: ASA Refresher Course Lectures 2001;153:2. 3. American Society of Anesthesiologists Peer-review in Anesthesiology: Standards Guidelines and Statements: Park Ridge, IL.,USA 1998. 4. Website of Indian Society of Anaesthesiologists:www.isaindia. org 5. Arbous M S, et al : Mortality associated with anaesthesia : a qualitative analysis to identify risk factors Anaesthesia 2001. 56(12) : 1141-53. 6. Prause G, List W F : The anaesthesiologic risk patient. Proportional evaluation, intra operative management and PO. Monitoring: Chirurg 1997 Aug 68(8) 775-9. 7. Faunce T A. Rudge B.: Deaths on the table. Proposal for international prevention on the investigation and prevention ofanaesthetic mortality : Med Law 1998;17(l):31-54. 8. Rustein D. D et al: Measuring quality of care : a clinical method: NEJM 1976:294:582-8. 9. Tinker J H etal : Role of monitoring devices in the prevention of anaesthetic mishaps; a closed claim analysis :Anesthesiology 1989;71:535-540. 10. Detsky A. : A Clinicians guide to cost effectiveness analysis: Ann Int Med. 1990; 113:147. 11. Fitch SV : The new technology assessment : NEJM 1990, 323. 673. 12. Hudson RJ, Friesen RM. : Health care reform and costs of anaesthesia: Can J. Anaesth 1993;40:1120-25. 13. Johnstone RE Martinec CL : Costs of Anaesthesia: Anest Analg . 1993; 76: 840-48. 4/3/2014 1:43 PM 81

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