Physiologic Monitoring of the Surgical Patient

NOLAN E. PECHO, MD, FPCS, FPSGS Assistant Professor Department of Surgery FEU-NRMF Institute of Medicine

Physiologic Parameters

Hemodynamic Respiratory Blood Gases Gastric Renal Neurologic Metabolic Temperature

Physiologic Monitoring

Surgeons involvement in critical care management:

Understand and enhance patients physiologic response Recognize and correct pathophysiologic challenges

Hemodynamic Monitoring

Rationale:

Provides information of CV status Traditional clinical assessment usually unreliable Major changes in CV status may not be clinically obvious Invasive monitoring techniques must be utilized

Hemodynamic Monitoring

Methods
1.
2. 3. 4.

Arterial catheterization Central venous catheterization Pulmonary artery catheterization Derived hemodynamic parameters

Hemodynamic Monitoring

Arterial Catheterization

Indications: a. Need for continuous blood pressure monitoring

1) 2) 3) 4) 5) 6) 7) 8)

Shock states Hypertensive crisis Extensive surgery in high risk patients Use of potent vasoactive or inotropic drugs High level of respiratory support (ventilator) High risk patients undergoing extensive surgery Controlled hypotensive anesthesia Any situation leading to rapid alteration in cardiac function

b.

Need for frequent arterial blood sampling

Hemodynamic Monitoring

Arterial Catheterization

Contraindications 1. NO Absolute contraindication 2. Relative contraindications

1. 2. 3. 4.

Bleeding problems Anticoagulant therapy Presence of vascular prosthesis Local infections

Hemodynamic Monitoring

Arterial Catheterization

Sites 1. Radial artery 2. Axillary artery 3. Femoral artery 4. Dorsalils Pedis artery 5. Superficial Temporal artery 6. Brachial artery

Hemodynamic Monitoring

Arterial Catheterization

Complications 1. Failure to cannulate 2. Hematoma formation 3. Disconnection with bleeding 4. Infection 5. Retrograde cerebral embolization 6. Arteriovenous fistula 7. Pseudoaneurysm formation 8. Severe pain 9. Distal ischemia, necrosis

Hemodynamic Monitoring

Central Venous Catheterization

Indication 1. Access for fluid therapy 2. Access for drug infusion 3. For parenteral nutrition 4. For CVP monitoring 5. Others:
1. 2. 3. 4.

Aspirate air embolism in neurosurgical procedure Placement of cardiac pacemakers Placement of inferior vena cava filters Hemodialysis access

Hemodynamic Monitoring

Central Venous Pressure

1.
2. 3.

4. 5.

Useful in hypotensive patients CVP tracing for arrhythmias Gives information about intravascular volume and right ventricular function relationship Electronic transducer will give tracing waves Water manometer for pressure measurement only

Hemodynamic Monitoring

Central Venous Catheterization

Sites 1. Subclavian vein 2. Internal jugular vein 3. External jugular vein 4. Femoral vein 5. Basilic vein 6. Brachiocephalic vein

Hemodynamic Monitoring

Central Venous Catheterization

Complications
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Catheter malposition Dysrhythmias Embolization Vascular injury Injury to other structure (neural) Cardiac injury Pleural cavity penetration Mediastinal injury Pneumothorax Arterial puncture Infection Thrombosis Thrombophlebitis

Hemodynamic Monitoring

Pulmonary Artery Catheterization

For monitoring the critically ill patients Values can predict: 1. Cardiac output 2. Pulmonary artery occlusion pressure 3. Systemic vascular resistance Indicated whenever data obtained will improve therapeutic decision making without giving unnecessary risk to patient

Hemodynamic Monitoring

Pulmonary Artery Catheterization

Parameters: 1. Central venous pressure 2. Pulmonary artery diastolic pressure 3. Pulmonary artery systolic pressure 4. Mean pulmonary artery pressure 5. Pulmonary artery occlusion pressure 6. Cardiac output 7. Mixed venous blood gases 8. Continuous mixed venous oximetry

Hemodynamic Monitoring

Pulmonary Artery Catheterization

Clinical Indication 1. Shock despite adequate fluid therapy 2. Oliguria despite adequate fluid therapy 3. Assess effect of intravascular fluid expansion on cardiac function 4. To delineate CV component of MODS 5. To differentiate noncardiogenic from cargiogenic pulmonary edema 6. To assess effect of high levels of ventilatory support on CV status

Hemodynamic Monitoring

Pulmonary Artery Catheterization

Clinical Indication 7. Pre-op assessment and peri-operative management of high risk surgical patients 8. Who need cardiac or major vascular surgery 9. Post-op CV complications 10. Multisystem trauma 11. Severe burns 12. CHF unresponsive to simple therapy 13. Pulmonary hypertension 14. MI complicate by pump failure or pulmonary edema 15. Treatment of unstable angina with IV nitroglycerin

Hemodynamic Monitoring

Pulmonary Artery Catheterization

Complication 1. Dysrhythmias 2. Transient right bundle branch block 3. Aberrant catheter placement 4. Infection 5. Thromboembolism 6. Rupture of the pulmonary artery

Hemodynamic Parameters
Calculation
Parameter Central venous pressure (CVP) Pulmonary artery systolic pressure (PASP) Pulmonary artery diastolic pressure (PADP) Mean pulmonary artery pressure (MPAP) Pulmonary artery wedge pressure (PAWP) Cardiac output (CO) Mixed venous oxygen saturation (SO2) Cardiac index (CI) Systemic vascular resistance (SVR) Pulmonary vascular resistance (PVR) O2 delivery (DO2) O2 consumption (VO2) CO/BSA (MAP CVP) X 80 CO MPAP PAWP X 80 CO CO X SaO2 X [Hgb] X 1.34 CO X {(SaO2 - SO2 ) X [Hgb] X 1.34} 0-7mm Hg 15-30mm Hg 4-12mm Hg 9-16mm Hg 2-12mm Hg 4.0-8.0L/min 0.65-0.80 fraction 2.8-4.2L/min/m2 900-1400 dyne X sec X cm-5 150-250 dyne X sec X cm-5 700-1400 ml/min 180-280 ml/min

Normal Value

Respiratory Monitoring

Monitoring ventilation and gas exchange Importance

1. 2.

3.
4.

Decision for need of mechanical support Assessment of response to therapy Optimizing ventilator management Decision for weaning from ventilatory support

Gas monitoring permits

1. 2.

Adequacy of oxygen transport Calculation of derived parameters

Ventilation Monitoring

Lung Volumes

Important to monitor in ICU and Operating room Parameters: 1. Tidal Volume 2. Vital Capacity 3. Minute Volume / Total Ventilation 4. Dead Space

Ventilation Monitoring

Tidal Volume (Vt)

Volume of air moved in and out of the lungs in any single breath Depressed tidal volume means difficult ventilation and oxygenation Spirometer for measurement Respiratory frequency (f) to Tidal volume ratio: i. If f / Vt ratio > 100 = respiratory failure ii. If f / Vt ratio < 80 = successful therapy, may wean from ventilatory support

Ventilation Monitoring

Vital Capacitiy (VC)

Maximal expiration following a maximal inspiration VC reduced in respiratory muscle disease or their neural pathway injury Depressed in restrictive and obstructive pulmonary disease Reduced in patient with elevation of diaphragm Values obtained are usually patient dependent

Ventilation Monitoring

Minute volume (VE) or Total Ventilation

Total volume of air leaving the lung each minute Product of Vt and f Increase in VE required to maintain oxygenation = increase dead space in relation to Vt or increased CO2 production Resting VE < 10 L = successful weaning

Ventilation Monitoring

Physiologic Dead Space

The portion of the tidal volume that does not participate in gas exchange Two components 1. Volume of gas within conducting pathways (anatomic dead space) 2. Volume of gas within unperfused alveoli (alveolar dead space)

Pulmonary Mechanics

Respiratory mechanical parameters

1.
2. 3. 4.

Maximal inspiratory pressure Static compliance of the lungs Dynamic compliance of the lungs Work of breathing

Pulmonary Mechanics

Maximal Inspiratory Pressure (PI max)

The maximal pressure below the atmospheric pressure that a patient can exert against an occluded airway PI max of more negative than 20 to 25 cm H2O = clinical parameter of recovery

Pulmonary Mechanics

Compliance

The elastic properties of the lung and chest wall Expressed as change in volume divided by the change in pressure Usual adult range = 60 100 ml/cm of H2O Values < 25 means difficult weaning or respiratory failure

Pulmonary Mechanics

Work of Breathing

Product of change in pressure and volume Measure of the process of overcoming the elastic and frictional forces of the lung and chest wall Three components in criticall ill 1. Normal physiologic work 2. Work to overcome the pathophysiologic changes in the lung and chest wall 3. Work to overcome the imposed work of breathing created by the methods of ventilatory support

Gas Monitoring

Blood Gas Analysis

Gives information about 1. Efficacy of gas exchange 2. Adequacy of alveolar ventilation 3. Acid-base status Blood gas values are usually reported as directly measured partial pressure of O2 and CO2 and calculated hemoglobin oxygen saturation (SO2)

Gas Monitoring

Capnography

Graphic display of CO2 concentration as a waveform Predictable relationship with arterial CO2 Monitoring is important in detecting pulmonary emboli Correlates with cardiac output and coronary perfusion during resuscitation

Gas Monitoring

Pulse Oximetry

Reliable, real time estimation of arterial hemoglobin oxygen saturation Wide clinical acceptance to its use in the ICU, ER, recovery room and operating room

Gas Monitoring

Continuous Mixed Venous Oximetry (SvO2)

Helpful in assessment of oxygen supply-demand relationship Incorporated in pulmonary artery catheter Three major functions: 1. Serves as indicator of adequacy of the O2 supply-demand balance or perfused tissue 2. Early warning or signal of untoward event 3. Cost-containment in the ICU

Pulmonary Variables
Description Abbreviatio n PaO2 Partial pressure of oxygen in arterial blood Partial pressure of oxygen in the alveolus Direct measurement 85-95 mm Hg (room air) 98-100 mm Hg (room air), 630670 mm Hg (FIO2 = 1.0) 35-45 mm Hg Derivation Normal Value

PAO2

[(PB - PH2O) X FIO2] PaCO2/0.8

PaCO2

Partial pressure of carbon dioxide in arterial blood

Direct measurement

PACO2

Partial pressure of carbon dioxide in the alveolus

Partial pressure of oxygen in mixed venous blood Partial pressure of carbon dioxide in mixed venous blood

Direct measurement

40 mm Hg

PmvO2

Direct measurement

40-45 mm Hg

PmvCO2

Direct measurement

45-50 mm Hg

A-aDO2

Alveolar-arterial oxygen gradient

Oxygen saturation of arterial hemoglobin

PAO2- PaO2

10-20 mm Hg (room air)

98% (room air)

SaO2

Direct measurement

Pulmonary Variables
S mvO2 Oxygen saturation of mixed venous hemoglobin Shunt fraction Direct measurement 75% (room air)

Qs/Q1

CcO2 - CaO2 CcO2 - Cmv2 VT X RR (PaCO2 - PECO2) X VT / PaCO2 (PaCO2 PECO2)/PaCO2 Direct measurement Direct measurement Direct measurement

5-8%

Vmin Vd

Minute ventilation Dead space ventilation

4-8 L/min

Vd/VT

Efficiency rating

VT VC FRC

Tidal volume Vital capacity Functional residual capacity Dynamic compliance Static compliance

4-5 ml/kg 65-75 ml/kg 2000-2500 ml

Cdyn Cstat

Exp. VT/(PAP - PEEP) Exp. VT/(plateau pressure - PEEP)

40-60 ml/cm H2O 80-100 ml/cm H2O

RR = respiratory rate; PECO2 = partial pressure of expired CO2; PAP = peak airway pressure; PEEP = positive end-expiratory pressure.

Gastric Tonometry

General Consideration

Relatively non-invasive monitor of adequacy of aerobic metabolism in organs whose superficial mucosal lining is extremely vulnerable to low flow changes GIT displays metabolic changes before other indices of oxygen utilization is apparent

Gastric Tonometry

TONOMETER used for measurement

Semipermeable balloon connected to a sampling tube TRIP NGS: dual-purpose tube, a tonometer in combination with a standard gastric sump Balloon allowed CO2 generated in the superficial mucosa to equilibrate with the saline instilled into the balloon Intramucosal pH (pHi) - measured and calculated

Gastric Tonometry

Clinical Utility

Incomplete splanchnic cellular resuscitation associated with: Multiple organ system failure Frequent septic complication Increased mortality As a predictor of both organ dysfunction and mortality Better predictor of mortality than the base deficit, lactate, oxygen delivery and oxygen consumption Provide clinically with a metabolic end-point of resuscitation based on pHi

Renal Monitoring

Major Indications
1.

2. 3. 4.

Kidney is an excellent monitor of adequacy of perfusion Prevention of acute parenchymal renal failure Predict drug clearance and proper dose adjustment Source of infection / sepsis

Renal Monitoring

Urinalysis

Simple test, commonly used Results imply: Presence of infection State of hydration Hematuria Metabolic problems Renal parenchymal disorders Renal tubular disorders

Renal Monitoring

Urine Output

Commonly monitored; may be misleading May give false sense of security Very low output 1. Renal failure 2. Obstructive uropathy 3. Dehydration / hypovolemia Very high output 1. Osmotic diuresis 2. Non-oliguric renal failure 3. Hypervolemia

Renal Monitoring

Blood Urea Nitrogen (BUN)

Affected by GFR and urea production Increased if large amount of nitrogen are administered during TPN, GI bleeding or in catabolic states due to trauma, sepsis or steroid use Urea production may be lowered during starvation and in advanced liver disease Not a reliable monitor of renal function

Renal Monitoring

Plasma Creatinine

Directly proportional to level of creatinine production Inversely related to GFR Not influenced by protein or nitrogen metabolism or by the rate of fluid flow through the renal tubules Will double its value if GFR is reduced by 50% Creatinine production is directly related to muscle mass and its metabolism

Renal Monitoring

Creatinine Clearance

Values of plasma creatinine affected by diseases affecting the muscles Serial determination is necessary Most reliable method of assessing the GFR

Renal Monitoring

Tubular Function Test

Test that measures the concentrating ability of the renal tubules Used to establish the etiology of oliguria as pre-renal or parenchymal Utility depends on the ability of the renal tubular cells to physiologically respond to a decreased extracellular fluid volume Useful in oliguric patient

Renal Monitoring

Functional Excretion of Sodium (FE Na)

The most reliable laboratory test for distinguishing pre-renal azotemia from acute tubular necrosis Requires only simultaneously collected spot urine and blood samples Calculation: FE Na (%) = U Na / P Na x 100 U Cr / P Cr Normal value: 1 2 % Value < 1 pre-renal cause of oliguria Value > 2 acute tubular necrosis

Laboratory Findings in PRERENAL AZOTEMIA and ACUTE TUBULAR NECROSIS

TESTS PRERENAL AZOTEMIA > 20 / 1 > 1.8 > 40 ACUTE TUBULAR NECROSIS < 15 / 1 < 1.1 < 20

BUN/creatinine ratio Urine/plasma osmolar ratio Urine/plasma creatinine ratio Urine osmolality (mOsm/L) Urinary sodium conc. (mEq.L) FE Na (%)

> 500 < 20

< 350 > 40

<1

>2

Neurologic Monitoring

Early recognition of cerebral dysfunction Facilitate prompt intervention in situation when aggressive treatment favorable influence outcome Values must always be clinically correlated Glasgow coma scale useful for quick assessment
1.
2. 3.

Eye response Verbal response Motor response

Neurologic Monitoring

Intracranial Pressure Monitoring

ICP permits calculation of cerebral perfusion pressure CCP = ICP MAP (mean arterial pressure) CPP at least 70 mmHg is recommended Indication 1. Severe head injury 2. GCS less than 8

Neurologic Monitoring

ICP Monitoring

Methods Ventricular catheter Subarachnoid bolt Epidural bolt Fiberoptic catheter Complication 1. Infection 2. Hemorrhage 3. Malfunction 4. Obstruction 5. Malposition

Neurologic Monitoring

Electophysiologic Monitoring

Electroencephalogram (EEG) Reflects spontaneous and on-going electrical activity of the brain Intra-operative use primarily to: Monitor adequacy of cerebral perfusion during carotid endarterectomy

Neurologic Monitoring

Transcranial Doppler Ultrasound (TCD)

Monitor cerebral blood flow Detect vasospasm

Neurologic Monitoring

Jugular Venous Oximetry

Measures jugular bulb oxyhemoglobin saturation Relationship between total cerebral blood flow and total cerebral oxygen consumption To minimize secondary insults after severe head injury by facilitating recognition of cerebral ischemia Indication: monitoring Neurosurgical procedures Carotid endarterectomy Cardiopulmonary bypass

Metabolic Monitoring

Caloric demands Respiratory quotients of food Caloric Value of Metabolic Substrates

kcal/g
Carbohydrate Fat Protein 4.0 9.5 4.8

kcal/L O2
5.0 4.7 4.5

RQ
1.0 0.7 0.8

Temperature Monitoring

Must get the core temperature

1.
2. 3.

Rectal probe Esophageal probe Ear probe