Monitoring© Jones & Bartlett Learning, LLC NOT for SALE OR DISTRIBUTION NOT for SALE OR DISTRIBUTION CONTENTS

■■ Intraoperative Monitoring Standards ■■ EKG © Jones & Bartlett■■ Cuff Blood Learning, Pressure LLC © Jones & Bartlett Learning, LLC NOT FOR SALE■■ Arterial OR LineDISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Central Venous Catheter (CVP) or CV Catheter (CVC) ■■ Pulmonary Artery Catheterization (PAC) Monitors or PA Pressure (PAP) © Jones & Bartlett Learning,■■ Mixed LLC Venous Oxygen Saturation © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION(SvO2 or MvO2) NOT FOR SALE OR DISTRIBUTION ■■ Transesophageal Echocardiograph (TEE) ■■ Leveling Transducer and Calibrating Invasive Lines ■■ Pulse Oximetry ■■ Capnography and ETCO2 © Jones & Bartlett Learning, LLC ■■ Neuromuscular Blockade© Jones Monitoring & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ■■ Neurologic: EEG andNOT BIS FOR SALE OR DISTRIBUTION ■■ Neurophysiology Monitoring ■■ Temperature Monitoring

9781284115147_CH03_083_136.indd 83 27/10/16 2:37 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALE ORDISTRIBUTION © Jones& BartlettLearning,LLC 9781284115147_CH03_083_136.indd 84

Monitors • evaluated. tion, circulation, andtemperature shouldbecontinually allanesthetics,During thepatient’s oxygenation, ventila- 84 Records the electrical differenceRecords theelectrical right between the and (aVL),and foot right (aVR),left (aVF) Unipolar: Augmented LimbLeads for Pwaves. detecting III. Onlyoneleadcanbeexaminedat atime. Lead IIis best from 3angles. Allowsactivity monitoring ofleadsI,II,and 3-lead system cangive oftheheart’s pictures electrical oneleadpositiveBipolar: andtheothernegative. The 3-lead System • • • ischemia intraoperatively. The EKG may provide thefirstindication of myocardial increases your ability to do this monitoring quickly and increases and your to dothismonitoring quickly ability and temperature canbeassessed. The useoftechnology ofcirculation, and auscultation ventilation, theadequacy esthesia provider. Through theuseofvisualization, palpation, No monitor, however, replaces thepresence ofavigilant an- • • • efficiently, butnoneoftheseadv Basic Monitoring Standards ■■ ■■ Oxygenation: FiO II + V4 + V5 =98%sensitive for ischemicevent II + V5 =80%sensitive for ischemicevent V5 =75%sensitive for ischemicevent Temperature: temperature probe Circulation: EKG, bloodpressure, pulseoximetry Ventilation: alarm capnography; disconnect

3.1 Intraoperative Monitoring Standards central negative lead. foot andtheleft (allpositive arms leads)utilizinga left Lead inischemiadetection. placement isimportant 3.2 EKG © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Chapter 3

Monitoring 2 analyzer; pulseoximetry analyzer; NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC ances replaces YOU.

NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC 07/11/16 3:05 PM NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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–+I RA LA – – © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION III II

– – © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

+ aVF © Jones & Bartlett Learning,Figure 3-2 EKG Augmented LLC Leads © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 86 of theheart. stand why theindividualleads represent specificareas the positive polesare ineachleadhelpyou to under to thelimbandprecordial where leadsand picturing theheart’sImagining central orientation inrelation • • • Full 12-leadEKG Represent theheart’s orientation onatransverse plane, neutral center. withanelectrically Unipolar: Eachindivid- Precordial Leads) Leads (V Precordial leads(unipolar) Augmented limbleads(unipolar) Standard limbleads(bipolar)

providing a three-dimensional view.providing athree-dimensional cally over ventricle. areas oftheleft ual V leadisthepositive pole. They are placed anatomi- © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Chapter 3

Figure 3-3 Monitoring NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC

EKG Precordial Leads NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

07/11/16 3:05 PM NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 87 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION I Vector moving towards Positive QRS the positive lead, the QRS complex upright. III Vector moving at right Equiphasic QRS angle to leads axis, the QRS complex will be © Jones & Bartlett Learning, LLC © Jones &equiphasic. Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION aVR NOT FORVector SALE moving away OR DISTRIBUTION Negative QRS from the positive lead, the QRS complex will be negative. Figure 3-4 Vector and Waveform Direction

© Jones & ItBartlett is similar to takingLearning, pictures with LLC a camera from different © Jones & Bartlett Learning, LLC NOT FOR SALEangles. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION V1 and V2 represent the intraventricular septum. V3 and V4 lie approximately over the anterior left ventricle. V5 and V6 approximate the lateral left ventricular wall. Monitors

© Jones & Bartlett Learning,■■ 3.3 Cuff LLC Blood Pressure © Jones & Bartlett Learning, LLC Cuff pressures are used often in healthy patients under- NOT FOR SALE OR DISTRIBUTIONgoing a short surgery. NOT FOR SALE OR DISTRIBUTION Cons: Blood pressure readings by cuff are normally very reliable and accurate, but motion (especially shivering), certain arrhythmias (irregular heart rhythms lead to unidentical pulse waves), or the surgeon leaning against the cuff will cause false readings or failure to © Jones & Bartlett Learning, LLC get a reading. Other difficulties© Jones with & using Bartlett a cuff for Learning, LLC NOT FOR SALE OR DISTRIBUTION blood pressure readingsNOT are the FOR interruption SALE of IV OR DISTRIBUTION infusions, issues with flow, or injury from repeated/ frequent cuff inflation.

Formula for mean arterial pressure (MAP) = SBP + (2 × DBP) / 3 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 87 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors The widthofthecuffshouldbe40%circumference Values may be in error ifthecuffisnotproper size. Cuff Size 88 Intracranial operations resections Pulmonary centralMajor orperipheral vascular surgery bypass Cardiac surgery—cardiopulmonary Line Indications for Arterial blood gassampleswillbeneeded. tiple arterial orwhen tight controlexpected ofbloodpressure ormul- Used inany casewhere widebloodpressure swingsare top ofthebrain canbeasmuch as9mmHg.) tween thebaseofbrain [Circle of Willis] andthevery the brain “sees.” (Additionally, thepressure difference be- site ofcuffmeasurement. This willbethe MAP thebaseof 0.75 mmHgfor height above every cmofvertical the brain shouldbecalculated by decreasing thecuff MAP by and thebrain). The bloodpressure for thebaseof is thehydrostatic pressure gradient between theheart between thebrain andthebloodpressure cuff(difference pressure cuff, distance know the itiscrucial to vertical thesittingpatient’sIf pressure ismeasured by ablood Position andBloodPressure by Cuff problems fromOther overzealous cuffuse ■■

▪ of theextremity 3.4 Arterial Line 3.4 Arterial ▪ ▪ ▪ ▪ ▪ ▪ ▪ © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Too small—falselyhighreading IV infiltration damage nerve Too low reading large—falsely Chapter 3

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 89 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Major trauma procedures Deliberate hypotension Patient exhibiting • pulmonary disease © Jones & Bartlett Learning, LLC • cardiac disease © Jones & Bartlett Learning, LLC • metabolic derangements NOT FOR SALE OR DISTRIBUTION • obesity NOT FOR SALE OR DISTRIBUTION Contraindications Specific to site selection • Raynaud’s disease • Allen’s Test (this is controversial) © Jones & Bartlett▪▪ Allen’s Test: Learning, Assess collateral LLC circulation of hand © Jones & Bartlett Learning, LLC NOT FOR SALE▫▫ occlude OR both DISTRIBUTION radial and ulnar arteries NOT FOR SALE OR DISTRIBUTION ▫▫ patient squeezes fist until hand blanches ▫▫ release ulnar artery with hand open ▫▫ normal—color returns in < 5 seconds

▫▫ abnormal—color returns in > 15 seconds Monitors • Systolic Arterial Pressure (SBP): assessment of © Jones & Bartlett Learning,myocardial LLC oxygen demand © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONUpstroke Dicrotic notch NOT FOR SALE OR DISTRIBUTION Anacrotic limb Dicrotic limb

120 Systolic 120 mmHg Pulse pressure = 40 mmHg 93

NOT FOR SALE OR DISTRIBUTION AUC- NOT FOR SALE OR DISTRIBUTION Area under MAP = AUC + Base = 93 curve End-diastolic pressure

Base © Jones & Bartlett Learning,Figure 3-5 Arterial LineLLC Waveform © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 89 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors • 90 descending limb of arterial pressureDicrotic limb:descending trace limbofarterial Systolic decline:area between thepeaksystolic pressure Indicates peripheral vascular resistance. Downstroke • • • • Steepness ofascending limbisaffected by: Upstroke • organs. Pressure Arterial the Mean (MAP): theMAP perfuses arteries. what fillsthe coronary myocardial oxygen supply. The diastolic pressure is arterial tree arterial Anacrotic limb:occurs bloodinto asventricles eject of theupstroke. prolong therate ofthepressure increase andtheangle ventricular inotropic state; impaired can contractility Myocardial (inotropic contractility state): indexofleft (more steep incline)andvasodilators (lesssteep incline) Systemic vascular resistance (SVR): through vasopressors rate Heart Diastolic Ar

notch is a part of thelimb.notch isapart Assesses SVR. as pressure fallsto thediastolic pressure. The dicrotic to return pressure. to end-diastolic time isincreased because ofthelengthtimeittakes the dicrotic limbangleisless acute anddownstroke tree.rial stenosis), patients withincreased In SVR(aortic dicrotic limbdueto low pressure inthesystemic arte- temic vascular resistance (SVR).Low SVRshows asteep end-systole changesinrelation to early-diastole) to sys- obstruction). (i.e., (LV) tricle isfinishedwithejection LV outflow tract systole comes to anabrupthaltbefore ven- theleft and thedicrotic notch; declineismore rapid when © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, The angleofthedicrotic limb(therate offallfrom Chapter 3 terial Pressure (DBP):assessment of

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 91 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Dicrotic notch: occurs as pressure fluctuates when the aortic valve shuts during the descending arterial limb. Assesses systemic vascular resistance. Varies with which artery the line is placed. © Jones & Bartlett Learning, LLC ▪▪ Signifies onset of diastole© Jones & Bartlett Learning, LLC ▪▪ Flat notch: dehydration or valve insufficiency NOT FOR SALE OR DISTRIBUTION ▪▪ Low notch: high pulseNOT pressure FOR due to SALE poor vascular OR DISTRIBUTION resistance (i.e., low diastole) Diastolic runoff: area between the dicrotic notch and the end-diastolic pressure—indicates the decline in arterial pressure as ventricular contraction comes to an end. © Jones & AreaBartlett under Curve Learning, (AUC): reflects LLC estimation of stroke © Jones & Bartlett Learning, LLC NOT FOR SALEvolume OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Pulse pressure (PP): force that the heart generates each time it contracts:

PP = systolic – diastolic pressure Monitors

© Jones & Bartlett Learning,Normal LLC: 40 mmHg © Jones & Bartlett Learning, LLC Narrow or low PP: seen with low flow states (drop in NOT FOR SALE OR DISTRIBUTIONleft ventricular stroke volume) such as: aorticNOT ste- FOR SALE OR DISTRIBUTION nosis, heart failure, shock, tension pneumothorax, cardiac tamponade, pulmonary embolism Wide or high PP: seen with high flow states such as: aortic regurgitation, warm stage of septic shock, exercise. Arteriovenous malformation, © Jones & Bartlett Learning, LLC hyperthyroidism/thyroid© Jones storm. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Pulse pressure variationNOT (PPV): FORvariations SALE in wave OR DISTRIBUTION size during respiration, allows for goal-directed fluid management in mechanically ventilated patients. PPV can be measured both by arterial line or non- invasively to estimate stroke volume and cardiac output. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 91 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 92 Brachial Axillary Ulnar Radial Different line: sites to place anarterial LinePlacementArterial Locations Bisferiens tracing: Anacrotic notch abnormality seenin: fluctuation Respiratory Normal: <13 A 135

45 90 ▪ ▪ ▪ ▪ 0 ▪ ▪ ▪ ▪ © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, hypertrophic, cardiomyopathy obstructive (HOC) stenosis; aortic insufficiency; withaortic Seen Second systolic notch canbeseen. intravascular volume state: dehydration mechanical ventilation p Chapter 3 t Figure 3-7 Figur

Monitoring e 3-6

Bisferiens Tracing

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC Pulse P Pulse ressure Variation 1 sec

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 93 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Femoral Dorsalis Pedis Systolic Pulse Amplification Difference in arterial waveforms according to site of © Jones & Bartlett Learning, LLC insertion. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Systolic peak is steeper theNOT further FOR down the SALE arterial treeOR DISTRIBUTION it travels. When compared to the aorta, the systolic blood pressure can increase by as much as 20 mmHg at the radial artery. From central to peripheral: © Jones & Bartlett▪▪ More peaked Learning, in amplitude LLC © Jones & Bartlett Learning, LLC ▪▪ Systolic higher NOT FOR SALE▪▪ Diastolic OR lower DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▪▪ Lower mean ▪▪ Dicrotic notch disappears Monitors Aortic Root © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Subclavian NOT FOR SALE OR DISTRIBUTION

Axillary

Brachial © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTRadial FOR SALE OR DISTRIBUTION Femoral Dorsalis Pedis

© Jones & Bartlett FigureLearning, 3-8 Systolic Pulse LLC Amplification © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors • Lines” formoreinformation) “Leveling(See Transducer Calibrating and Invasive Lines Arterial Leveling Transducer andCalibrating 94 • evaluated. needstoright ventricular bemonitored function or Used inany casewhere intravascular volume status or • • • • • • • • Line Complications withArterial • ■■ Supine position a pressure transducer usingfluid-filled tubing. ismeasured byCVP coupling theintravascular space to laceration Arterial Hematoma formation Thrombosis/ischemia dysfunction Nerve Impaired circulation Infection Air emboli Hemorrhage at adifferent height from heart) chairposition(oranyBeach positionwhere theheadis ▪

or CV Catheteror CV (CVC) 3.5 Central Venous Catheter (CVP) The horizontal reference point to level andcalibrate the ▪ mid-axillary line mid-axillary of theatria, isleveled at the4thintercostal space, axis,” “phlebostatic A widelyusedreference point inleveling isthe © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, the brain. mates thepressure delivered to theCircle of Willis in meatus becauseitbestapproxi auditory - external the headdifferent isthe from thelevel oftheheart bloodpressure transducerarterial inapatient with Chapter 3

Monitoring whichcorresponds to thelevel NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 95 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • CVP pressure is calibrated at the level of the vena cava or the right atrium. • CVP measurement: patient flat, measure at end expiration • The CVP normal range is 2 to 6 mm Hg © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CVP Line Is Required or Useful for NOT FOR SALE OR DISTRIBUTION • Measurement of the rightNOT heart FORfilling pressuresSALE to OR DISTRIBUTION assess intravascular volume (preload) and right heart function. • Administration of medications centrally • Anticipated inotropic medication infusion • Massive transfusion/large amounts of volume as with © Jones & Bartlettsurgery on heart, Learning, great vessels, LLC mediastinal structures © Jones & Bartlett Learning, LLC NOT FOR SALE• Parenteral OR nutrition DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Venous access—poor peripheral sites • Aspiration of air embolus • Insertion of pacemaker Central Line Contraindications Monitors • Severe coagulopathy © Jones & Bartlett Learning,• Infection LLC at site © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Right atrial tumor NOT FOR SALE OR DISTRIBUTION • Tricuspid valve vegetation • Anticoagulation • Ipsilateral carotid endarterectomy • Right atrial tumor or clots that could be dislodged • Bundle branch blocks are a relative contraindication © Jones & Bartlett Learning, LLC Leveling Transducer ©and Jones Calibrating & Bartlett CVP Line Learning, LLC NOT FOR SALE OR DISTRIBUTION Supine or sitting positionNOT FOR SALE OR DISTRIBUTION A widely used reference point in leveling for a CVP reading is the “phlebostatic axis,” which corresponds to the level of the atria—it is leveled at the 4th intercostal space, mid-axillary line. © Jones & CVPBartlett measured Learning,when patient is flatLLC and at end-expiration. © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 95 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 96 • • • Internal JugularRight (RIJ) of embolismanddistends thevessels. jugular orsubclavian; thisposition decreases therisk in Done Trendelenburg inthe positionwheninserting Veins andAnatomy ChestandNeck ofUpper PlacementCVP surgical intervention. severe puncture enoughto requirecarotid artery damage, forRisk venous nerve airembolism,and ▪ ▪ ▪ Insertion as highonrightandavoidsnot rise (onleft). thoracic duct accessRight-sided preferred becauseapicalpleura does commonMost site for placement. CVP

▪ ▪ ▪ nipple. Cannula aimeddown andlateral toward ipsilateral of SCMandclavicle. low approach,In formed triangle by two heads Patient positionedheaddown. © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Chapter 3

Figure 3-9 Monitoring NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC

Leveling T 0° 30° ransducer 60° NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

07/11/16 3:05 PM

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Path of internal jugular vein

Clavicle

© Jones & Bartlett Learning,Figure LLC 3-10 CVP Insertion Landmarks for RIJ placement© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONLeft Internal Jugular (LIJ) NOT FOR SALE OR DISTRIBUTION • Technically more difficult • Increased risk of chylothorax (leakage of lymphatic fluid from the thoracic duct into the pleural space) and pleural effusion • Potential for carotid artery puncture severe enough to © Jones & Bartlett Learning, LLC require surgical intervention© Jones & Bartlett Learning, LLC • Nerve damage NOT FOR SALE OR DISTRIBUTION • Venous air embolism NOT FOR SALE OR DISTRIBUTION Subclavian Vein Insertion • Patient positioned head down • Insertion at subclavian has a lower infection rate but © Jones & Bartletthigh rate of pneumothoraxLearning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors • • Femoral • • • • • • Jugular External • • 98 • High incidence of line-related sepsis rate incidence ofline-related High anywhere else rarely,Done usuallyonlyifcan’t getcentral line Phlebitis Kinking/migration puncture arterial Inadvertent mayStops extension help) inaxilla(arm Valves makeitdifficult tothread in Done Trendelenburg position Vein encountered 4–5cm after Needle aimedtoward suprasternal notch clavicle andpassesimmediately behindclavicle lateral 1/3oftheclavicle; approached from below Needle insert

Inser jugular vein clav © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Clav Internal head SCM tion point icular jugular vein icle Chapter 3 External Figure 3-11 ed below junction ofmedial2/3and ed below junction

Monitoring

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CVP Waveform CVP waves are created by pressure changes in right © Jones & Bartlett Learning, LLC atrium during both diastole© andJones systole. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION The CVP Waveform InterpretationNOT FOR SALE OR DISTRIBUTION + a wave: This wave is due to the increased atrial pressure during right atrial contraction. It correlates with the P wave on an EKG. + c wave: This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ven- © Jones & Bartletttricular contraction. Learning, It correlates LLC with the end of the © Jones & Bartlett Learning, LLC NOT FOR SALEQRS segment OR DISTRIBUTIONon an EKG. NOT FOR SALE OR DISTRIBUTION – x descent: (1st downstroke) This wave is caused by the downward displacement of the ventricle and tricuspid valve during systolic contraction. It occurs

before the T wave on the EKG. It signifies atrial Monitors relaxation. © Jones & Bartlett Learning,+ v wave: ThisLLC wave arises from the pressure produced© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONwhen the blood filling the right atrium comesNOT up FOR SALE OR DISTRIBUTION against a closed tricuspid valve. It occurs as the T wave is ending on an EKG. – y descent: (2nd downstroke) This wave is produced by the opening of the tricuspid valve in diastole with blood flowing into the right ventricle. It occurs before © Jones & Bartlett Learning, LLC the P wave on an EKG. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION CVP Waveform AbnormalitiesNOT FOR SALE OR DISTRIBUTION • large a wave = tricuspid stenosis, right ventricular failure, pulmonary stenosis, pulmonary hypertension • cannon “a” waves are abnormalities in the “a wave” that occur when right atrial contraction takes place against a closed tricuspid valve. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 100 tracing Jugular tracing ECG CVP ECG

c YTL DIASTOLE SYSTOLE e 3-13 Monitoring x

P NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC CVP WaCVP

T CVP Trace CVP CVP Waveform andEKG a v veform Componentsveform y Q R S c a x T NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC c

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 101 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▪▪ Classically occurs in 3rd degree heart block or AV dissociation, nodal rhythm. ▪▪ Unlike “large a waves,” which are uniform in height and are observed during each cardiac cycle, cannon “a waves” are variable in height and occur sporadically © Jones & Bartlett Learning, LLC because of the variable© relationshipJones &of atrial Bartlett Learning, LLC contraction to ventricular systole. NOT FOR SALE OR DISTRIBUTION • no a wave = atrial fibrillationNOT FOR SALE OR DISTRIBUTION • no x wave = triscuspid regurgitation • large v wave = tricuspid regurgitation Complications Placing Central Lines • Early © Jones & Bartlett▪▪ Hemorrhage Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE▪▪ Air embolus OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▪▪ Pneumothorax ▪▪ Cardiac arrhythmias ▪▪ Pericardial tamponade

• Late Monitors ▪▪ Venous thrombosis © Jones & Bartlett Learning,▪▪ Infection LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION■■ 3.6 Pulmonary Artery CatheterizationNOT (PAC) FOR SALE OR DISTRIBUTION or PA Pressure (PAP) Primarily a PAC is inserted to assess left ventricular function, but other information can also be derived regarding valvular disease, myocardial damage, and response to blood pressure interventions. © Jones & Bartlett Learning, LLC Indications: Assess cardiac© Jones output/index, & checkBartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION preload/volume status, SVONOT2. FOR SALE OR DISTRIBUTION • Estimate of LA pressure and ultimately LV pressure • Estimates of LAP, which is an estimate of LVEDP, which is an estimate of LVEDV. • LV preload • LV end diastolic pressure (LVEDP) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 101 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 102 • • • • • • • • • • • Derived Information SvO CO/CI Left ventricular enddiastolic pressure (LVEDP) Left ventricular stroke work index(LVSWI) ▪ ▪ Vascular Resistance and SVindex(SVI) Stroke volume (SV) wedge pressure (PCWP) artery Pulmonary pressures systolic, diastolic, andmean artery Pulmonary ventricularRight stroke work index (RVSWI) ventricularRight systolic anddiastolic pressures pressure (RAP) Central venous pressure atrial (CVP)—Right ▪ ▪

RA Pulmonary (PVR,PVI) Pulmonary Systemic (SVR,SVRI) © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, II 2 Chapter 3 P QRS Figure 3-14

Monitoring A X V NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC

Y CVP Cannon VWave CVP PVC

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NOT FORSALE ORDISTRIBUTION © Jones& BartlettLearning,LLC © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Blue = proximal = CVP. . . run CO through blue port Yellow = PA = distal Dark blue = RV port

© Jones & Bartlett Learning, LLC Contraindications to ©Placing Jones PAP & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Absolute NOT FOR SALE OR DISTRIBUTION ▪▪ Tricuspid or pulmonary valve stenosis ▪▪ RA or RV masses ▪▪ Tetralogy of Fallot ▪▪ Severe arrhythmias (or high-risk arrhythmias, i.e., Wolff-Parkinson–White syndrome) © Jones & RelativeBartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE▪▪ Coagulopathy OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▪▪ Left bundle branch block ▪▪ High-risk arrhythmia (i.e., Wolff-Parkinson– White–WPW)

▪▪ New pacer wires Monitors Complications of PAC Insertion © Jones & Bartlett Learning,• Same as LLC CVP plus some additional © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Dysrhythmias (frequent) NOT FOR SALE OR DISTRIBUTION • Cardiovascular stress • Hemorrhage • Thromboemboli • Infection • Cardiac trauma/PA perforation © Jones & Bartlett Learning, LLC • Complete heart block © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION PA Insertion NOT FOR SALE OR DISTRIBUTION Check balloon before inserting—must be concentric and must cover tip when inflated Usually inserted into right or left internal jugular Inserted through a large bore introducer (sheath) © Jones & EachBartlett black mark Learning, is 10 cm on PAC LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 103 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 104 PA

mmHg 50cm 40cm L Antecubital R Antecubital S Femoral Vein Jugular Left Internal common site RIJ—Most Jugular (RIJ) InternalRight Location blva 10–15cm ubclavian C isaflow directed catheter—needto heartbeat output. protect endocardium andhelppropel tipthrough RV with ballooninflated fromRA; inflating balloonwill chambers. Mustfloat through catheter heart insert 10 20 30

Monitoring Wav Atrium Distance to Right 04 m5–5c 60cm 55cm 50–55cm 45–50cm 30–40 cm 20–25 cm 20 cm RIJ to right atrium @20cm+10to and then+5cmforwedge =50cm eform withPAC andPressures Insertion + 10–15to PA =40–45cm NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC RV 20/2 15.000 RV RV =30cm 07 m80cm 70cm 70–75 cm 40cm 60–65 cm 30–35 cm 04 m50cm 40–45 cm artery Pulmonary to Inserted 15.300 PA 20/12 mean 15 PA NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

PA wedge Wedge PCWP mean 5–15 6–12

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(SvO2 or MvO2)

SvO2 is the oxygen saturation in venous blood and is also referred to as mixed venous oxygen saturation. It is the © Jones & Bartlett Learning, LLC measurement of the balance© Jonesbetween, and & alterationsBartlett Learning, LLC in, O2 consumption and delivery—represents oxygen NOT FOR SALE OR DISTRIBUTION “reserve,” the amount of oxygenNOT that FOR can be SALE utilized OR DISTRIBUTION during periods of increased demand. Simply, it is a measurement of the end result of oxygen consumption and delivery at a tissue level. Measured in the pulmonary artery from a mixture of all systemic venous blood drain- ing from all tissue capillary beds (except shunted blood). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALESvO2 = oxygenOR DISTRIBUTION demand (SaO2, Hgb, cardiac output) – NOT FOR SALE OR DISTRIBUTION oxygen consumed (VO2)

Continuous SvO2 monitoring (with an oximetric pulmonary artery catheter [PAC], which contains fiberoptic bundles that measure oxygen by reflectance spectrom- Monitors etry) provides a measure of oxygen remaining in the © Jones & Bartlett Learning,venous blood LLC after passing through the capillary© bed. Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONSvO2 is calculated by the differential absorptionNOT of light FOR SALE OR DISTRIBUTION by saturated and desaturated Hgb (like pulse ox). Best measured from pulmonary artery as adequate mixing has occurred. Sometimes, blood can be drawn from the right ventricle but not from the right atrium as bloods are not adequately mixed that far proximal.

Normal SvO2: sufficient oxygen supply to tissues (60–80%) © Jones & Bartlett Learning, LLC Generally, the tissues of© a restingJones individual & Bartlett use Learning, LLC NOT FOR SALE OR DISTRIBUTION approximately 25% of theNOT available FOR oxygen, SALE leaving an OR DISTRIBUTION oxygen reserve of 75% for periods of increased activity or physiologic stress.

Mixed venous oxygen saturation (SvO2) normal range is 60–80%, meaning anywhere from 20–40% of oxygen is extracted by the tissues and 60–80% returned to the right © Jones & heart.Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 105 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors than 3–5minutes. should beconsidered significant ifitpersists for longer 106 High SvO • • Decreased oxygen demandandconsumption Increased SvO Increased oxygen demandandconsumption Increased oxygen supplyanddelivery is decreased. sumption ishigh.Adrop inSvO • • andintopast thecapillaries thevenous blood. bloodis shunted arterial ofbloodflow; maldistribution Decreased oxygen supply tissue oxygenation iscompromised. oxygen demandisexceeding oxygen consumption and Anesthesia (musclerelaxation) Hypothermia Sepsis blood) mixes withcapillary Wedged PA catheter (bloodinfront ofthecatheter Decreased SvO Any deviation greater than10%from patient’s baseline Measurements outsidenormalrange ▪ ▪ ▪ ▪ ▪ Either oxygen delivery isincreasedEither oxygen oroxygen delivery demand Either oxygen supplyisinsufficientoxygen or con-

▪ ▪ ▪ ▪ ▪ © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Increased FiO sepsis seizures,hyperthermia, malignant hyperthermia, Fever, shivering, thyroid storm, agitation, pain, cardiac dysrhythmias) Decreased cardiac output(hypovolemia, shock, hypoxiaArterial (suctioning) Decreased hemoglobin(bleeding, anemia) Chapter 3 2 but organ hypoxia—most common causeis 2 (> 80%)

Monitoring 2 2 (< 60%) NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC 2 isawarning sign that

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• Left to right shunts (increased SvO2 in spite of oxygen tissue deprivation) Compensatory mechanisms kick in if oxygen delivery is decreased and/or oxygen consumption is increased to © Jones & Bartlett Learning, LLC ensure adequate oxygenation© Jones to tissues. &The Bartlett two most Learning, LLC important compensatory mechanisms are: NOT FOR SALE OR DISTRIBUTION • When oxygen demand NOTincreases, FOR the body SALE attempts OR DISTRIBUTION to increase delivery of oxygen primarily through an increase in cardiac output. • If CO does not increase, the tissues will extract a larger amount of oxygen from the available supply. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ 3.8 Transesophageal Echocardiograph (TEE) NOT FOR SALETEE is more OR accurate DISTRIBUTION than transthoracic techniques. NOT FOR SALE OR DISTRIBUTION

Used to Evaluate • Regional wall motion abnormalities indicative of Monitors myocardial ischemia • Stroke volume/ejection fraction © Jones & Bartlett Learning,• Global ventricularLLC function © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Intracardiac air embolism NOT FOR SALE OR DISTRIBUTION • Intravascular fluid volume

Intraoperative Diagnosis • Early ischemia and air embolus • Evaluation of hypotension © Jones & Bartlett Learning, LLC • Evaluation of intracardiac© valveJones repairs & Bartlett Learning, LLC • Diagnostic for aortic disease and dissection NOT FOR SALE OR DISTRIBUTION • Assess intracardiac massNOT FOR SALE OR DISTRIBUTION Limitations • Equipment is bulky and expensive • Requires extensive training and experience • Qualitative versus quantitative data © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 107 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors • • • • Potential Risks 108 Can zero at level any intheroom vertical without creating face at thestopcock establishingareference pressure. “Zeroing” exposesthetransducer to theair-fluid inter • to aspecificpoint onthepatient. “Leveling” thetransducer assigns azero reference point • • Relative Absolute Contraindications ■■ Atrial andventricular arrhythmias bleeding Minor Vocal cord paralysis Esophageal perforation ▪ transducer moves. Level orifpatient, before bed, or lineinsertion Left atrial myxoma ofembolization withhistory Coagulopathy orheparinization ▪ ▪ Invasive Lines 3.9 Leveling Transducer andCalibrating ▪ ▪ ▪ ▪

▪ mid-axillary line mid-axillary of theatria—it isleveled at the4thintercostal space, “phlebostatic axis,” A widelyusedreference point inleveling isthe Supine position ofesophagealsurgery History Esophagitis © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Esophageal pathology ▫ ▫ ▫ ▫ ▫ ▫ Scleroderma Varices Stricture Chapter 3

Monitoring NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC whichcorresponds to thelevel NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 109 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION error since atmospheric pressure is the same at floor or ceiling. • When transducer is open to air (stopcock turned toward patient), the transducer is measuring the pressure of the atmosphere, which is 760 mmHg at sea level. © Jones & Bartlett Learning, LLC • Zeroing done before line© insertion Jones and & first Bartlett reading. Learning, LLC

NOT FOR SALE OR DISTRIBUTION ■■ 3.10 Pulse OximetryNOT FOR SALE OR DISTRIBUTION

Oxygen saturation (SaO2) is a measurement of the amount of oxygen bound to hemoglobin (Hgb). Hemoglobin consists of four iron groups (heme) attached to a protein (globin). Each heme molecule can carry one molecule of © Jones & oxygen,Bartlett so each Learning, molecule of hemoglobin LLC can bind four © Jones & Bartlett Learning, LLC molecules of oxygen. Oxygen saturation is the ratio of the NOT FOR SALEamount of OR oxygenated DISTRIBUTION hemoglobin to the total hemo- NOT FOR SALE OR DISTRIBUTION globin in 100 ml of blood. It is frequently expressed as a percentage.

Factors with no effect on SaO2 • Bilirubin, fetal hemoglobin (HbF), sickle hemoglobin Monitors (HbS), acrylic nails, fluorescein dye © Jones & Bartlett Learning,Errors in pulse LLC ox monitoring (falsely low reading)© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Low perfusion states NOT FOR SALE OR DISTRIBUTION • Optical interference: Sensor can pick up external light • Motion • Anemia Hgb < 5 gm/dL • Hypothermia • IV dyes (i.e., methylene blue) • Electrocautery © Jones & Bartlett Learning, LLC • Nail polish (esp. dark reds© andJones blues) & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • Cardiac arrhythmias mayNOT interfere FOR with theSALE oximeter OR DISTRIBUTION picking up the pulsatile signal properly Inaccurate pulse ox reading (falsely high or low reading) • Abnormal Hgb (i.e., carboxyhemoglobin, methemoglobin © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 109 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors Capnography: thedisplay ofCO : themeasurementCapnometry ofend-tidalcarbon measured by capnometry. The presence dioxide ofcarbon inexhaledgascanbe 110 Analyzed for: height, frequency, baseline, shape Capnography Waveform • • Capnography vs. Pulse Ox: ■■ Capnography measures ventilation; ETCO oxygenation withinminutes. changesin reflects RBCs goingoutfrom theheart; Pulse measures percentage oximetry ofoxygen on within seconds. dioxide;exhaled carbon changesin reflects ventilation dioxide 3.11 Capnography andETCO ▪ ▪ absorption.

▪ ▪ © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, between end-tidalandPaCO alveolar deadspace andreferred to asthegradient The PaCO The value normal ofETCO A–B Baseline;devoid ofCO Chapter 3 B Expiration begins; rapid rise 2 is2–5mmHghigherthanETCO

B–C Expiratory PlateauC–D Expiratory Monitoring Inspiration beginsE Inspiration D ETCO Inspiration ends A Inspiration Expiratory Upstroke Expiratory NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC 2 measured 2 is35–37mmHg. 2 ; read by infrared light 2 2 ; deadspace 2

2 measures

NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC 2 —reflects —reflects 07/11/16 3:05 PM NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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I II III IV D © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC E NOT FOR SALE OR DISTRIBUTION C NOT FOR SALE OR DISTRIBUTION

A © Jones & BartlettB Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONTime NOT FOR SALE OR DISTRIBUTION

Figure 3-16 ETCO2 Capnography

I steady state – inhalation ends, exhalation begins (A–B) Monitors

II rapid rise in CO2 concentration as anatomical dead © Jones & Bartlett Learning, LLCspace is replaced with alveolar gas (B–C)© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONIII alveolar equilibrium (C–D) NOT FOR SALE OR DISTRIBUTION IV inspiration (E–A)

The Alpha Angle • The angle between phases II and III, which increases as the slope of phase III increases. © Jones & Bartlett Learning, LLC • The alpha angle is an indirect© Jones indication & of Bartlett V/Q status of Learning, LLC NOT FOR SALE OR DISTRIBUTION the lung. NOT FOR SALE OR DISTRIBUTION • Airway obstruction causes an increased slope and a larger angle. • Other factors that affect the angle are the response time of the capnograph, sweep speed, and the respiratory cycle time. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 111 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 112 Metabolism Normal ETCO Other Increased cardiac Circulatory Rebreathing Pulmonary 54 mgElevated ETCO 35–45 mmHg Table 3.1 Table

Normal 2

Monitoring E TC hyperthermia Malignant Pain Hyperthermia S giv S Tourniquet release output Analgesia/sedation disease airway Chronic obstructive insufficiency Respiratory rate tory Decreased respira- hivering odium bicarbonate O en 2 35–45mmHg NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC , fever 2 ETCO rate,tory thelower the the higherrespira- the lower thebicarb, bicarb. The more acidic, to adecrease inserum minute ventilation due increasespensatory in decreases from com- Decreased ETCO ETCO shock state— Metabolic acidosisin Hypothermia Pulmonary embolism Pulmonary Cardiac arrest hypovolemia Hemorrhage/ Hypotension output Decreased cardiac Mucous plugging Bronchospasm in lungperfusion Any significant decrease obstruction Apnea/airway Hyperventilation 2. NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

2 2

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α α

Capnography Interpretation A. ETCO2 baseline above zero © Jones & BartlettRebreathing Learning, LLC © Jones & Bartlett Learning, LLC ▫▫ Faulty expiratory valve NOT FOR SALE▫▫ Inadequate OR DISTRIBUTION inspiratory flow NOT FOR SALE OR DISTRIBUTION ▫▫ Breath stacking (not fully exhaling)

▫▫ Exhausted/malfunction of CO2 absorber system B. Progressively increasing ETCO2 Monitors Anything that causes CO2 to rise: Gradual © Jones & Bartlett Learning,○ ○LLCHypoventilation © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION○○ Malignant hyperthermia NOT FOR SALE OR DISTRIBUTION ○○ Increasing body temperature ○○ Increased metabolism ○○ Partial airway obstruction

○○ Excessive CO2 production ○○ Absorption of CO2 from body cavity Sudden © Jones & Bartlett Learning, LLC ○○ Tourniquet release© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ○○ Bicarbonate administrationNOT FOR SALE OR DISTRIBUTION ○○ Reperfusion during vascular grafting C. Sudden rapid fall of CO2 close to zero ▫▫ Complete ETT disconnection from circuit ▫▫ ETT obstruction or kinked ▫▫ ETT cuff leak © Jones & Bartlett▫▫ Partial Learning,disconnect LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 113 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 114

Monitoring e 3-18

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC Capnograph Loss ofplateau Time y Waveforms

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

NOT FORSALE ORDISTRIBUTION © Jones& BartlettLearning,LLC © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 115 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▫▫ Leak in circuit or sampling tube ▫▫ Room air entrainment ▫▫ ETT in hypopharynx D. Sudden drop to zero ▫▫ Cardiac arrest © Jones & Bartlett Learning, LLC ▫▫ Apnea © Jones & Bartlett Learning, LLC ▫▫ Ventilator disconnection or malfunction NOT FOR SALE OR DISTRIBUTION ▫▫ Airway obstructionNOT FOR SALE OR DISTRIBUTION E. Decrease in wave size Exponential decrease in wave size (over 1–2 minutes) ○○ Circulatory arrest with continued mechanical ventilation © Jones & Bartlett○○ Severe Learning, hypotension LLC © Jones & Bartlett Learning, LLC NOT FOR SALE○ ○ORMassive DISTRIBUTION blood loss NOT FOR SALE OR DISTRIBUTION ○○ Pulmonary embolism Slow, gradual decrease in wave size (over 3–8 minutes) ○○ Hyperventilation

○○ Hypothermia Monitors F. Curare Cleft © Jones & Bartlett Learning,▫▫ Patient LLC attempting to breath over controlled© Jones & Bartlett Learning, LLC mechanical ventilation causes “curare cleft” NOT FOR SALE OR DISTRIBUTION▫▫ Surgeon’s hands in abdomen and pushingNOT FOR SALE OR DISTRIBUTION intermittently **capnography is very sensitive to movements or small changes in airway pressures G. Shark fin shape Continuous slanted upstroke with loss of expiratory © Jones & Bartlett Learning, LLC plateau—prolonged© expiratory Jones time & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ▫▫ COPD NOT FOR SALE OR DISTRIBUTION ▫▫ Wheezing ▫▫ Presence of foreign body in the airway ▫▫ Obstruction in expiratory limb of vent circuit ▫▫ Partially kinked or occluded artificial airway H. New onset slanted upstroke © Jones & Bartlett▫▫ Bronchospasm Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284115147_CH03_083_136.indd 115 07/11/16 3:05 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Monitors 116 : a single stimulus of 0.1 Hz every every Single twitch response: asinglestimulusof0.1Hz Train ofFour (TOF) ratio: four successive stimuliare de Five Commonly Used Patterns ofStimulation • • • • ■■ number ofreceptors blocked. seenorfeltNumber oftwitches canbequantified to theelectrodes. andtissuesunderlying of theskin determined by thevoltage generated andresistance The intensity ofthecurrent is that reaches thenerve Current outputinmoststimulators ranges from 0–80 is madeto thepatient. extubate assessing thepatient’s strength before afinaldecision andisacrucialmonitor in electrically a motor nerve stimulator (PNS)isusedtoA peripheral nerve stimulate differentiatetypes ofblock. between the to guiderepeated dosesofmusclerelaxants andto ismonitoredNeuromuscular surgery during blockade 10 secs or 1.0 every 1second at maximum current10 secsor1.0every done TOF stimulations. At least12secondsof block. shouldpassbetween The TOF stimulusprovides quantification ofthedepth islower twitch twitch).fourth thanthat ofthefirst neuromuscular blockincreases (i.e., theheight ofthe Twitches progressively fadeasnondepolarizing the firsthasbeendefinedas “train of four ratio.” released decreases by witheachstimulus. thenerve the stores are ofacetylcholine depleted andtheamount livered at 0.5second at intervals. At 2Hz thisfrequency, Monitoring 3.12 Neuromuscular Blockade I.

© Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, The ratio response oftheheight to ofthefourth Cardiac orjetoscilla ▫ ▫ ▫ ▫ ▫ ▫ Partially kinked or occluded artificial airway oroccluded artificial Partially kinked limbofvent inexpiratory circuitObstruction Presence offoreign bodyintheairway Chapter 3

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 117 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Table 3-2 TOF Response Blocked TOF Response Receptor Notes 4/4 < 70% Amenable to reversal with © Jones & Bartlett Learning, LLC © Jonesanticholinesterase & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORMay experience SALE weakness OR DISTRIBUTION even with a TOF 4/4 3/4 75% Amenable to reversal with anticholinesterase 2/4 80% Amenable to reversal with © Jones & Bartlett Learning, LLCanticholinesterase, requires © Jones & Bartlett Learning, LLC larger dosing than with TOF NOT FOR SALE OR DISTRIBUTION3/4 or 4/4 NOT FOR SALE OR DISTRIBUTION 1/4 85–90% Do not attempt reversal of neuromuscular blockade until

TOF > 2/4. Adequate relax- Monitors ation for short procedures. © Jones & Bartlett Learning,0/4 LLC 90–100% 95% of receptors© blocked— Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION only posttetanic NOTfacilitation FOR SALE OR DISTRIBUTION visible; corresponds to acceptable muscle relaxation for intra-abdominal surgery

to stimulate fibers in a nerve bundle. The intensity of © Jones & Bartlett Learning, LLC the evoked muscle response© Jones depends & on Bartletthow many Learning, LLC NOT FOR SALE OR DISTRIBUTION neuromuscular junctionsNOT are unblocked. FOR SALE OR DISTRIBUTION Double burst stimulation: to evaluate the difference of the second to the first response, double burst stimulation consists of two short tetani (50 Hz) separated by an interval long enough to allow relaxation (750 msecs) in a series of 3. A minimum of 12 to 15 seconds must elapse © Jones & Bartlettbetween two Learning, consecutive double LLC burst stimulations. © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 118 Tetanic stimula on anawake patient. 6minutes andshouldnot bedone thanevery often can beassessedby fade. Shouldnotberepeated more response isnotrequired asthedegree ofparalysis by drugsandprerelaxant neuromuscular blocking posttetanic count (PTC). evoked posttetanic iscalledthe detected twitches by stimulation singletwitch at 1Hz. The numberof fortion at 50Hz five seconds followed 3seconds later stimulation. Performed by applyingtetanic stimula- there to isnoreaction or asingletwitch TOF nerve evaluate thedegree when ofneuromuscular blockade

© Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, potentiatio Posttetani stimulation (DBS Double-burst Telany Train-of-four Stimulus Normal Evoked Fade isfirstnoted at 70% receptor occupancy Chapter 3 c n 3,2 tion andposttetanic count: doneto

) Monitoring Constant but Constant but Constant but Figure 3-19 diminished diminished diminished hs PhaseII Phase I betPeetPresent Present Absent NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC

PN S Twit Fade Fade Fade ch

Nondepolarizing

NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC Block Fade Fade Fade 07/11/16 3:06 PM NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 119 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION No twitch is seen with a very profound block but a response will be seen in the early stages of recovery. The number of posttetanic twitches correlates inversely with the time for spontaneous recovery of twitches. Mobilization and increased synthesis of acetylcho- © Jones & Bartlett Learning, LLC line occur during and after© Jones cessation of& tetanic Bartlett stimu- Learning, LLC lation. Thus, after tetanus, there is an increase in the NOT FOR SALE OR DISTRIBUTION amount of acetylcholineNOT released FOR in response SALE to nerve OR DISTRIBUTION stimulation and a single twitch evoked after cessation of tetanus may even be stronger than the pretetanic control. This is known as posttetanic facilitation. Pattern of Twitch Return © Jones & AnesthesiaBartlett providers Learning, need to know LLC if the diaphragm and © Jones & Bartlett Learning, LLC NOT FOR SALEthe pharyngeal/laryngeal OR DISTRIBUTION muscles are strong enough to NOT FOR SALE OR DISTRIBUTION extubate the patient, but since we cannot test these muscles with a stimulator, we must choose a muscle group with a similar response.

Muscle Relaxants—Most Resistant to Most Sensitive Monitors Diaphragm > muscles of larynx > corrugator supercilii © Jones & Bartlett Learning,muscles > LLC abdominal muscles > orbicularis oculi© > Jonesposte- & Bartlett Learning, LLC rior tibial = adductor pollicis > masseter > upper airway NOT FOR SALE OR DISTRIBUTIONmuscles NOT FOR SALE OR DISTRIBUTION Central Muscles • Larger muscles that are relatively resistant to muscle relaxants. The dose of muscle relaxant needs to be up to 2 times greater for central muscles than for peripheral muscles to achieve the same degree of © Jones & Bartlett Learning, LLC blockade. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • Includes the diaphragm,NOT muscles FOR of larynx, SALE corrugator OR DISTRIBUTION supercilii muscles, abdominal muscles, and orbicularis oculi • Quicker onset and recovery than peripheral muscles • If the accurate assessment of muscle relaxation onset is important, monitoring the facial nerve is more useful © Jones & Bartlettthan a peripheral Learning, muscle. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors • • • • Peripheral Muscles 120 Muscle: adductor pollicisulnarnerve Muscle: adductor most commonly usedfor neuromuscular Ulnar Nerve— • • • StimulationNerve PlacementElectrode for Peripheral • criteria. provides alarger margin ofsafety withextubation a greater degree; thus, monitoring aperipheral muscle the respiratory musclesare likelyto have recovered to pollicisisstrong,the adductor thenitisassumedthat parameters.assessing extubation theresponse If of to monitor pollicis isthebestnerve TOF response when aperipheral musclesuchastheadductor Monitoring movement, suchashiccoughing. pollicis doesnoteliminate ofdiaphragm thepossibility Even total elimination at oftwitches theadductor pollicis, masseter, muscles. upperairway pollicis, theadductor posterior tibial, Includes adductor relaxation buthave aslower onsetandlongeraction. Small, rapidly moving musclesthat are sensitive to muscle muscle. thediaphragmreflect more closelythanaperipheral relaxants. receptorsextrajunctional that are resistant to muscle exaggerated evoked response because oftheincreased stimulation onaparalyzedNerve limbwillshow an path; avoidnerve stimulation direct ofthemuscle. placementElectrode shouldbealongtheexpected is thenegative lead. placed inproximal positionto theheart. The blacklead The positive electrode, eitherred orwhite, shouldbe A cen monitoring

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Little nger Ulnar nerve © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONFigure 3-20 TOF Ulnar Nerve NOT FOR SALE OR DISTRIBUTION Monitor: thumb adduction Black (distal lead): 1–2 cm proximal to wrist

flexor crease Monitors White/Red: 2–5 cm proximal to black lead © Jones & Bartlett Learning,Notes: extend LLC the arm, palm up in a relaxed state.© TheJones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION2 electrodes are placed over the path of the ulnarNOT FOR SALE OR DISTRIBUTION nerve. Fingers can twitch if the electrodes are placed directly over the muscle. Facial nerve Muscle: orbicularis oculi and corrugator supercilii Monitor: orbicularis oculi (contraction of eyebrow), corru- © Jones & Bartlett Learning, LLC gator supercilii (pulling© the Jones eyebrow toward& Bartlett the nose) Learning, LLC NOT FOR SALE OR DISTRIBUTION Black: just anterior to tragusNOT of ear FOR SALE OR DISTRIBUTION White/Red: lateral to outer canthus of eye or on the forehead. Notes: the facial nerve comes from the brainstem and emerges behind the stylomastoid foramen moving forward to the lateral border of the orbit. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 122

Figure 3-22

TOF Orbic Monitoring NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC ularis Oculi andCorrugatorularis Oculi

TOF Oculi Orbicularis S NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC upercilii NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC Orbicular muscle supercilii Corrugat portion) (orbita muscle oculi

NOT FORSALE ORDISTRIBUTION © Jones& BartlettLearning,LLC © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Posterior Tibial Nerve Muscle: Flexor hallucis brevis Monitors Monitor: Plantar flexion of great toe © Jones & Bartlett Learning,Black: 2 cm LLC posterior to medial malleolus © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONWhite/Red: 2–3 cm proximal to black NOT FOR SALE OR DISTRIBUTION Notes: posterior tibial nerve is a branch of sciatic nerve.

Residual Neuromuscular Blockade Residual neuromuscular blockade can be defined by inadequate neuromuscular recovery as measured by © Jones & Bartlett Learning, LLC objective neuromuscular ©monitoring. Jones This & can Bartlett lead to Learning, LLC many physiological changes with impaired muscle tone NOT FOR SALE OR DISTRIBUTION and coordination: NOT FOR SALE OR DISTRIBUTION Upper airway pharyngeal and esophageal muscles Increased risk of aspiration Increased risk of airway obstruction © Jones & LaryngealBartlett muscles Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors Impaired ventilation andoxygenation muscles Respiratory Impaired cough Impaired phonation ofaspirationIncreased risk 124 • • • anesthesia. ing general anesthesia to assessfor awareness under BIS assessescentral system depression nervous dur- Index)BIS (Bispectral • • trodes are sometimesused. trodes placed alongthescalp, althoughinvasive elec- ofthebrain. Usually donewithelec- activity electrical Electroencephalography (EEG)isamonitor to record ■■ a direct measurea direct ofthe patient’s level ofconsciousness. calculates anumberbetween 0and100that provides The BISsystem processes theEEGinformation and the patient’s forehead. EEGinformationRaw isobtainedviaasensor placed on assessment. Newer technology allows current-time waveform assessment ofEEG,calculated over 15–30seconds. andgives useslesselectrodes (hypnosis). aglobal It as thedepthofanesthesiaincreases frequency changesinamplitudeandwhich predictably electroencephalogram (EEG), based onthesurface activity BIS measures electrical hypothermic arrest for cerebralMonitors isoelectricity protection during endarterectomy) areas ofcerebralDetects ischemia(carotid 3.13 Neurologic: EEGandBIS

in thebrain. I NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC t is

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 125 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▪▪ 70–100: moderate sedation to full awareness with intact memory ▪▪ 60–70: light hypnosis. Patient is more likely to have awareness. ▪▪ 40–60: ideal anesthetic state © Jones & Bartlett Learning, LLC ▪▪ 0–40: deep hypnosis © Jones & Bartlett Learning, LLC ▪▪ 0: indicates the absence of brain activity (cortical NOT FOR SALE OR DISTRIBUTION silence) NOT FOR SALE OR DISTRIBUTION Research has shown that BIS-monitored patients wake up faster, are extubated sooner, and are more oriented upon arrival to the PACU.

NOT FOR SALE OR DISTRIBUTIONFully awake to BIS 80–100 NOT FOR SALE OR DISTRIBUTION slightly sedated – Beta memory intact 12–24 Hz

80 Responsive to loud voice or touch Monitors

BIS 60–80 More sedated – © Jones & Bartlett Learning, LLCmemory intact ©Alpha Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT8–12 Hz FOR SALE OR DISTRIBUTION 60 Unresponsive to loud stimuli

BIS Index Range BIS 40–60 General Anesthesia Theta 4–8 Hz

Deep anesthetic BIS 0–40 NOT FOR SALE OR DISTRIBUTION – increasing burstNOT FOR SALE OR DISTRIBUTION Delta suppression <4 Hz

0 Flat-line electroencephalogram Figure 3-24 BIS Waveforms © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors • • • • BIS waveforms: • • Monitor Measurements alongwithBIS • • • • 126 • • and latencies oftheresponses that are monitored: “at risk” surgery. neural during structures pathways—done integrity to of monitor thefunctional ormotor stimulation ofspecificnerve sensory external responses ofthecen to irreversible damage. the brain, prior spinalcord, function orperipheral nerve tion. The goalofthismonitoring isto identify changesin surgeon inlocalizinganatomical dissec- during structures surgicalduring manipulations; itisalso usedto guidethe orinthepreventionlogic function ofneurological injury cation ofany pathologic condition that may alter neuro- Neurophysiological monitoring isvaluable intheidentifi- ■■ delta—wider loopy—unconsciousness theta—first stagesofsleep awake alpha—quiet awake beta—tiny flat; low amplitude—very index:how accurateSQI—quality theBISnumberis. burst suppression. SR—suppression ratio: theamount oftheEEGthat isin Patient movement EKG Pacer spikes Electrocautery BIS readings are affected by: from baseline. Amplitude isameasure ofthepeakwaveform the generated potential. thetimebetween thestimulus and describes Latency All EPs are describedinterms ofamplitude, shape, Evoked Potentials (EP): theelectrophysiologic 3.14 Neurophysiology Monitoring

Monitoring tral nervous systemtral inresponse nervous to NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 127 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 6 4 2 © Jones & Bartlett Learning, LLC 0 Latency © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION –2 NOT FORAmplitude SALE OR DISTRIBUTION Amplitude ( µ V) –4 –6 0 100 200 300 © Jones & Bartlett Learning,Latency LLC (msec) © Jones & Bartlett Learning, LLC NOT FOR SALE OR FigureDISTRIBUTION 3-25 Latency and Amplitude NOT FOR SALE OR DISTRIBUTION When used in intraoperative monitoring, changes in latency and amplitude from baseline responses are the most important indicators of neurological dysfunction.

Alarm criteria Monitors • 50% decrease in amplitude (amplitude changes have © Jones & Bartlett Learning,been implicated LLC as the most sensitive measure© of Jones & Bartlett Learning, LLC cerebral ischemia) NOT FOR SALE OR DISTRIBUTION• 10% increase in latency NOT FOR SALE OR DISTRIBUTION I Sensory Evoked Potentials 1. Somatosensory evoked potentials (SSEP): done to assess the functional integrity of afferent nerve pathways; the speed of a stimulus in the ascending © Jones & Bartlett Learning, LLC dorsal (posterior) and© lateral Jones sensory & pathways Bartlett of Learning, LLC spinal cord is measured. SSEP is unable to test the NOT FOR SALE OR DISTRIBUTION motor pathway, a significantNOT FOR limitation SALE of this test.OR DISTRIBUTION Technique: SSEP is produced by stimulation of a peripheral nerve wherein a response in the cortex, spinal cord, or nerve can be measured. Electrical stimulus ascends the spinal cord through the dor- © Jones & Bartlettsal roots, Learning,ascends to the third-order LLC fibers to the © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 128 2.

affect onlyonesideofthebody. clamp)canbeabruptandlocalized andmay artery orischemia(e.g.,distraction) placement after ofan responsetex where ismeasured. cortical Brainstem audit midline). evoked potentials (note “leg” inhomunculusis isplaceding electrode midlineto record tibialnerve laterally inthemotor homunculus. The SSEPrecord medially, whilethehandandface are located more note that thelower are extremities located more bybe dictated thesite ofstimulation. For example, placement for recording SSEPfrom thescalpwill cedures, cross-clamping andaortic cardiac bypass pro- aneurysm, coabdominal aortic anterior andposterior cerebral thora- aneurysms; vascular surgery, includingendarterectomy, and posterior fossa; supratentorial intracranial; cranial/ posterior fusions, andpediclescrew procedures; mies, laminectomies, corpectomies, anterior and roots, withnerve discecto- spinalsurgery: nerves, ▪ ▪ thalamus, thenont (ABR). potentials brainstem (AEP), responses andauditory evoked evoked responses auditory (BAER),auditory other terms for thistechnique includebrainstem ▪ ▪ ankle or peroneal nerve at theknee. orperoneal nerve ankle Lower at the posterior tibialnerve extremity—the radial nerve. (most common), canalsobedoneat ulnaror at thewrist mediannerve Upper extremity—the Common sites ofstimulation: Change dueto surgical maneuvers (e.g., spinal Motor Homunculus: The choice ofelectrode to themajorperipheral Clinical Uses: surgery Chapter 3

Monitoring ory evokedory potentials (BAEP): NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC o thecontralateral cor- sensory NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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Hip

Trunk

Knee Arm Elbow

Shoulder Wrist Hand Ankle Upper arm

Brain Eyelid and eyeball Face

Lips and jaw

Tongue

Figure 3-26 Motor Homunculus Monitors

© Jones & Bartlett Learning,Technique: LLC BAEP measures brainstem activity© Jones for & Bartlett Learning, LLC cranial nerve VIII. Auditory evoked potential can be NOT FOR SALE OR DISTRIBUTIONused to trace the signal generated by a soundNOT (audi FOR- SALE OR DISTRIBUTION tory clicks in the ear) through the ascending auditory pathway. The evoked potential is generated in the cochlea and goes through the cochlear nerve, to the midbrain, and finally to the cortex where recordings are obtained by standard EEG scalp electrodes © Jones & Bartlett Learning, LLC (best results obtained© near Jones the ears). & This Bartlett recording Learning, LLC NOT FOR SALE OR DISTRIBUTION provides an index ofNOT disturbance FOR secondary SALE to isch OR- DISTRIBUTION emia of the cochlear nerve and the divisions of the brainstem. Clinical uses: Good for posterior fossa or where brainstem is at risk, vestibular nerve, cerebellopon- tine angle surgery, acoustic neuroma, posterior © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 130 4. 3.

pituitary adenomas, andsuprasellar meningiomas.pituitary impairment—they includecraniopharyngiomas, significantrisk ofvisual that inthisarea arise carry ways, especiallyintheparasellar region astumors occipital cortex. there. Potentials are recorded over withelectrodes andhowsignal reaching fast thevisual cortex itgets ofthebrain.cortex VEPmeasures thestrength ofthe retina andtravels to through thevisual theopticnerve tering theeye isconverted into electrical energy atthe diodes(LED) orstrobelight-emitting lights. Lighten- formed inproximity to thevisualapparatus. visual pathways per- haspotential insurgery utility Visual ev spasm. decompression for ticdouloureux orhemifacial lesions of specific nerve roots,lesions ofspecificnerve brachial plexussurgery. matomes exists. Problems becauseoverlap canarise between der- from oneanotherinasingledermatome.ters apart SSEPs. regards are to amplitudeorlatency thesameaswith roots.individual nerve SSEPs donot provide information ontheintegrity of MuchlikeSSEP, cortex. somatosensory mary though signal viathedorsalcolumn pathways to thepri- ofa ascending root conduction tonerve ascertain tion ofasingledermatome to depolarize asingle Dermatomal E fossa, br Clinical nearopticpath- uses:usefulfor surgery Technique: visualstimulation isdoneby flashing Clinical uses:spinabifida/tethered cord releases, Technique: are electrodes placed several centime- Anatomical pathways with criteria andalarm Chapter 3 ainstem lesions, orfor microvascular oked: monitoring of potentials (VEP)

Monitoring voked Potentials (DEPs): stimula- NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 131 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION II Motor Evoked Potentials (MEP) MEPs monitor efferent corticospinal (motor) tracts of the ventral (anterior) spinal cord. Tongue biting is the most common complication, and placing bite blocks must be done to prevent serious damage. © Jones & Bartlett Learning, LLC Technique: electrical stimulation© Jones is performed & Bartlett transcra- Learning, LLC NOT FOR SALE OR DISTRIBUTION nially over the motor cortex.NOT The stimulusFOR isSALE propagated OR DISTRIBUTION via motor pathways that descend to the anterior spinal cord via the corticospinal tract. It then travels via a peripheral nerve to produce a muscle response. Significant motor deficits have been seen in patients undergoing spinal surgery despite normal SSEPs. MEPs © Jones & wereBartlett developed Learning, to better monitor LLC the motor neurophysi- © Jones & Bartlett Learning, LLC ological pathways, and their use in combination with SSEP NOT FOR SALEappears to OR improve DISTRIBUTION the accuracy of monitoring spinal NOT FOR SALE OR DISTRIBUTION cord function. Clinical Uses: MEPs are used in procedures with anterior approaches to spinal cord, abdominal aortic aneurysms,

scoliosis, spinal cord tumors, decompression and fusion Monitors spinal vertebrae. © Jones & Bartlett Learning,The use LLC of MEP is contraindicated in patients© with Jones & Bartlett Learning, LLC epilepsy, increased intracranial pressure, or cochlear NOT FOR SALE OR DISTRIBUTIONimplants. NOT FOR SALE OR DISTRIBUTION Anesthesia and MEP: muscle relaxants can depress myoneural transmission; check with surgeon before giving. III Spontaneous Potentials © Jones & Bartlett Learning, LLC 1. Electromyography© (EMG): Jones EMG is &monitored Bartlett for Learning, LLC spontaneous (can also be induced) electrical activ- NOT FOR SALE OR DISTRIBUTION ity. Practically any muscleNOT can FOR be monitored, SALE includ- OR DISTRIBUTION ing face, tongue, and sphincter musculature. Technique: multiple recording EMG needles are placed directly into the muscles of interest. Alarm criteria in monitoring is the “presence of EMG”; © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors 132 • • Intraoperative EPChangesMay Resultfrom ▪ ▪ ▪ ▪ ▪ ▪ ▪ Nonspecific physiologic factors orischemia Surgical injury ▪ ▪ ▪ ▪ ▪ ▪ ▪ 3. 2.

Hemodilution/decreased hematocrit Hypoxia interference Electrical PaO PaCO Hypotension Hypothermia/hyperthermia blood flow © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning,

for stimulation of the brain. seizures electrical during marginsresection andto for monitor epilepsysurgery itisusedto helpdetermine ofthecortex; cal activity - to read electri ontheexposedbraindirectly surface Electr pressure and/orcerebral bloodflow. technique may changesinsystemic reflect blood changes that cannotbeexplainedby anesthetic changes withdeepeninglevels ofanesthesia.Any operative EEGrecording ofexpected isknowledge arrest. requirementThe mostimportant for intra- repair hypothermic andduring circulatory aneurysm carotid cerebral butalsoduring endarterectomy commonly Most usedduring ofthecortex. activity along thescalpto read spontaneous electrical Electr be used. screw placement rhizotomy, tethered spinalcord release, pedicle monitoring, spinalexploration andfusions;dorsal activity. istheabsenc normal 2 Anesthesia withEMG:musclerelaxation cannot cranial nerve Clinical Uses: facialnerve/other dueto ischemiaofcerebral tissues Chapter 3 2 dueto changesinspinalcord andcerebral ocorticography (ECoG): are electrodes placed oencephalogram placed (EEG):electrodes

Monitoring NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC e ofspontaneous muscle NOT FOR SALE ORDISTRIBUTION © Jones &Bartlett Learning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 133 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Effects of Anesthetics on Evoked Potentials and EEG Evoked potentials are affected by almost all anesthetic agents, some quite significantly. Anesthetics exert their effects on the brain by depressing cerebral metabolism. © Jones & Bartlett Learning, LLC Electrophysiologist will© instruct Jones what agents& Bartlett may or Learning, LLC NOT FOR SALE OR DISTRIBUTION may not be used and theirNOT dose limits. FOR SALE OR DISTRIBUTION • Volatile anesthetics ▪▪ The volatile agents, which include the halogenated anesthetics and nitrous oxide, have the most potentially deleterious effect of all anesthetics on EPs. All cause similar depression of amplitude and © Jones & Bartlettincrease in Learning, latencies. MAC of LLC volatile (including © Jones & Bartlett Learning, LLC nitrous oxide) should be minimized to 0.5 or less; NOT FOR SALEhowever, OR successful DISTRIBUTION monitoring has been done NOT FOR SALE OR DISTRIBUTION up to 1.0. ▪▪ They affect cortically evoked responses more than subcortical, spinal, or peripherally evoked responses. At high concentrations, most also can suppress Monitors epileptiform discharges. © Jones & Bartlett Learning,• Propofol LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION▪▪ Increases latency and decreases amplitudeNOT of cortical FOR SALE OR DISTRIBUTION evoked potentials. • Etomidate ▪▪ In low doses, etomidate can increase evoked potential amplitude but prolong latencies. At induction doses, amplitude may be reduced. • Ketamine © Jones & Bartlett Learning, LLC ▪▪ Ketamine either does© not Jones affect or &may Bartlettincrease Learning, LLC NOT FOR SALE OR DISTRIBUTION evoked potential amplitude.NOT DoFOR not use SALE in patients OR DISTRIBUTION with intracranial pathology. • Narcotics ▪▪ Narcotics cause mild reduction in amplitude of evoked potentials but usually allow consistent monitoring. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors • • • 134 • • AnesthesiaDuring should becontinually evaluated. thetics, amongothermonitoring devices, thetemperature Basic monitoring standards that allanes- dictate during BAEP–EEG–SSEP–VEP Sensitive to Anesthesia—LeastSensitivity to Most • ■■ Neuromuscular blockers ▪ Benzodiazepines ▪ Dexmedetomidine andclonidine ambient temperatures (asoccur withexposedbody Adults to large subjected evaporative lossesorlow area to volumedue to theirhighsurface ratio. andsmallchildrenInfants are prone to lability thermal ▪ Barbiturates ▪ 3.15 TemperatureMonitoring ▪ ▪ ▪ ▪

amplitude withlittleeffect onlatencies. Benzodiazepines usuallyresult indecreased considered safe to EPmonitoring. useduring Have EPs minimaleffect on andarecortical epileptiform spikes. (e.g., methohexital)sometimescanincrease activity.beta frequency Fast-acting barbiturates be obtaineddespite highdoses. They alsoincrease and increase latency, recordings buttypically can These may decrease evoked potential amplitude as well. complete, suppresses evoked muscularresponses and,signals from if spontaneous muscleactivity potentials. Musclerelaxation reduces artifactual These agents have nosignificant effecton evoked © Jones & Bartlett Learning, LLC. NOTFOR SALEORDISTRIBUTION © Jones&BartlettLearning, Chapter 3

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chapter 3 Monitoring 135 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cavity, large volume transfusion of unwarmed fluids, or burns) are prone to hypothermia. • Malignant hyperthermia is always a possible complication (when volatile anesthetics or succinylcholine are used), and temperature monitoring is one step in its diagnosis. © Jones & Bartlett Learning, LLC • Anesthesia inhibits thermoregulation.© Jones &Causes Bartlett Learning, LLC redistribution hypothermia; heat loss > heat production. NOT FOR SALE OR DISTRIBUTION • Heat transfer to cold operatingNOT roomFOR (most SALE to least) OR DISTRIBUTION radiation > convection > evaporation > conduction. Benefits of Hypothermia • Tissue metabolic rate decreases ~8%/1°C decrease in temperature. © Jones & • BartlettProtects heart Learning, due to decreased LLC myocardial oxygen and © Jones & Bartlett Learning, LLC NOT FOR SALEmetabolic OR demand. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • CNS protection; improved neurologic outcomes after cardiac arrest. Consequences of Hypothermia Monitors • Coagulopathy (esp. platelets), increased blood loss • Increased infection rate; delayed wound healing; © Jones & Bartlett Learning,jeopardizes LLC graft success © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Increased drug duration of action and delayedNOT FOR SALE OR DISTRIBUTION emergence • Left shift of the oxyhemoglobin dissociation curve (tissue hypoxia)

• Increased postoperative shivering and increased O2 consumption (400% increase) © Jones & Bartlett Learning, LLC Prevent Hypothermia© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • Warmed air (Bair hugger)NOT FOR SALE OR DISTRIBUTION • Radiant heat lamps • Fluid warmer • Circuit heat and humidification moisture exchanger • Warm OR temperature © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE© Jones OR & Bartlett DISTRIBUTION Learning, LLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Monitors • • • • • • • • Obtained with Blood Temperature Measurements May Be 136 Axillary and skin: inaccurate andskin: Axillary venousby return extremity andstool doesnotcorrelateRectum: withcore temp; affected correlatesBladder: outputishigh withcore ifurinary goodestimate ofcoreOropharynx: temperature intheoperatingnot practical room environment Tympanic membrane: correlates withcore temp but correlates withcoreNasopharynx: temperature be located at thelower third oftheesophagus Esophagus: correlates withcore temp; probe should standard)—“core” temperature catheter (gold artery Thermistor ofapulmonary

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