Essentials of Anaesthetic Monitoring in Veterinary Practice
Transcript of Essentials of Anaesthetic Monitoring in Veterinary Practice
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AMVAC/RoSAVA 2014
Essentials of Anaesthetic
Monitoring in Veterinary
Practice A refresher and update lecture
By Prof Yves Moens, Dipl ECVAA
Presented by Dr Alessandra Bergadano, Dipl ECVAA
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
Technical Monitoring human
From 1864 to 2010
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AMVAC/RoSAVA 2014
Technical monitoring for vets
Bulky, fixed
paper recordings
Compact, portable
Usb-stick
eighties today
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
A fine combination
• 1. Capnometry/graphy
• 2. Pulsoximetry
• 3. Elecrocardiography
• 4. Blood pressure
• 5. Temperature
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AMVAC/RoSAVA 2014
Capnometry/graphy
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Continuous measurement of CO2 in respiratory gas
• Displayed numbers
– ETCO2: content of „end tidal“ part
– FICO2: content in inspiratory gas
• Principle = infrared spectroscopy
• Curves :“capnogram“
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Continuous measurement of CO2 in
respiratory gas, why?
• Idea: ETCO2 = ± PaCO2
• = continuous, non invasive measurement
of PaCO2
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AMVAC/RoSAVA 2014
Capnometry/graphy
Principle
Capnogram
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AMVAC/RoSAVA 2014
Capnometry/graphy
1969
1999
2009
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AMVAC/RoSAVA 2014
Capnometry/graphy
Various combinations
with and without Wave
forms
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Ventilation
• Circulation
• Metabolism
Essential for correct interpretation !!
ETCO2 depends of:
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AMVAC/RoSAVA 2014
Capnometry/graphy
Classical side stream
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AMVAC/RoSAVA 2014
Main stream Side stream
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Info on the efficacy of ventilation: PaCO2 is
determined by ventilation (min vol)
- info:hyper- or hypoventilation
- info:respiratory rate
- no info on respiratory volumes !!
• Apnoe monitor
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Definitive confirmation of correct
endotracheal tube placement !
Oesophageal intubation is a very common mistake!
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Control of pulmonary perfusion: ETCO2 is low
when:
– Low cardiac output
– Mismatch of Ventilation/Perfusion
– Pulmonary embolus
• Best detector of acute circulatory deficiency
(cardiac arrest, imminent cardiac arrest)
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AMVAC/RoSAVA 2014
Low CO and cardiac arrest –anaesthetic overdose
Air embolism from infusion line
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Control of the efficacy of external or internal
cardiac massage
• ETCO2 during cardiac massage is a good
help for prognosis of reanimation efforts
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Control of correct removal of expired CO2 from
anaesthetic circuits trough control of FICO2
– Semi-open systems like Bain, T-piece
• Necessary minimal flow guided by FICO2
instead of fixed values/kg
– Circle systems
• FICO2 as a guide for replacement of carbon
dioxide absorber when exhausted
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Control of the correct function of the
inspiratory and expiratory valves of a circle
system
• Detection of disconnections tube- circuit
• Detection of big leaks like eg from non
insufflated cuffs
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Extremely important monitor
• For interpretation the acknowledment of 3
contributors to the value is important: Ve-Ci-Me
• Needs correct technical sampling of gas (side
stream)
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AMVAC/RoSAVA 2014
Capnometry/graphy
• Intubation in principle necessary
• Capnograms are necessary for detailed interpretation
• Main stream is advantageous for small tidal volumes and high respiratory rates
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AMVAC/RoSAVA 2014
Pulsoximetry
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AMVAC/RoSAVA 2014
Pulsoximetry
• Continuous non invasive measurement of the
saturation of arterial hemoglobin SpO2 and
heart rate
• Dual wavelenght infrared Spectroscopy
• Correct interpretation supposes familiarity
with the oxyhemoglobin dissociation curve
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AMVAC/RoSAVA 2014
Pulsoximetry
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AMVAC/RoSAVA 2014
Oxyhemoglobin dissociation Curve
80 mmHg = 90%
90 mmHg = 95%
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AMVAC/RoSAVA 2014
Pulsoximetry
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
Pulsoximetry • During anaesthesia (immobility
• Intensive Care-Recovery : more difficult
(movement)
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AMVAC/RoSAVA 2014
Pulsoximetry
SpO2 80%
„HR“ X
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AMVAC/RoSAVA 2014
Measurement artefacts for SpO2
Factor effects on SpO2 Reading
Carboxy Methemoglobin to high
Pigmentation variable (to low)
Hypoperfusion variable (to low)
Vasoconstriction variable (to low)
Arrythmies variable(to low)
Hypothermie variable (to low)
Movement variable(to low)
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AMVAC/RoSAVA 2014
Pulsoximetry
• Strenght of of the electronic signal ?
• Amplitude and morphology of the
photoplethsysmographic curve?
• Replace and remesure
• Coulour of the muquous membranes ?
Difficult measurement during vasoconstriction
Displayed number (low) real??
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AMVAC/RoSAVA 2014
Pulsoximetry
SpO2 can be normal (>95%) during severe
hypoventilation when animals are receiving O2
supplementation
FIO2 = 21% : SPO2 if PaCO2
FIO2 > 30 % : SPO2 if PaCO2
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AMVAC/RoSAVA 2014
Pulsoximetry : clinical interpretation
• A low SpO2 value in an O2 supplemented
breathing patient is to be investigated for:
– Measurement artefact
– Important Circulation problem: low cardiac
output
– Important right to left shunt (collapsed lung
areas)
- pneumothorax, lung contusion, one lung intubation ,
lung compression by hernia etc
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AMVAC/RoSAVA 2014
Pulsoximetry
• Information less “robust” then capnography
• Values suspect during peripheral vasoconstriction
• Display of curves advised
• Detection of hypoventilation possible if FIO2 21%
• Limited sensitivity for ventilation changes during
gazeous anaesthesia, (FIO2 !)
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AMVAC/RoSAVA 2014
Capnography and pulsoximetry
The combination of both capnography and pulsoximetry during anaesthesia has the potential to warn and to avoid 93% of possible lethal complications
Tinker, 1998
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AMVAC/RoSAVA 2014
P
Q
R
S
T
Electrocardiography
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AMVAC/RoSAVA 2014
Electrocardiography
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AMVAC/RoSAVA 2014
Electrocardiography
• Heart Rate
– Essential information indicating many
different problems during anaesthesia
– also obtainable from pulsoxymetry
• Disturbances of cardiac rhytm
– Potentially severe problem
– Essential for differential diagnosis of cardiac
arrest
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AMVAC/RoSAVA 2014
Electrocardiography
• Quality of the signal important
– Adhesive electrodes
– Subcutaneous needle placement
– Crocodile clamps
• Practical alternative: Esophageal ECG
– Simple and practical (less cables)
– Stable good quality signal
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AMVAC/RoSAVA 2014
Electrocardiography
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AMVAC/RoSAVA 2014
P
Q
R
S
T
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AMVAC/RoSAVA 2014
Blood Pressure
• Why measuring?: to help to maintain mean
arterial blood pressure ≥70 mmHg. This
should garanty organ perfusion (not always)
• Invasive BP measurement:superior precision
– technically difficult
• Non invasive measurement:simple, practical
automated method for routine!!
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AMVAC/RoSAVA 2014
Blood Pressure
• Non invasive: Oscillometry (sys/dias/MAP)
– Moderate accuracy especially during:
• Low MAP
• Small patients
• When low values:
– Technical control of system application
– Clinical control of patient
– Treat the hypotension
• Excellent technique for detecting Trends
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AMVAC/RoSAVA 2014
Blood Pressure • High Definition Oscillometry (HDO)
– Improved accuracy
– Available in „stand alone“
• Doppler method
– Cheap - less practical
– Systolic Pressure only
– Non automated
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AMVAC/RoSAVA 2014
Blood Pressure
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AMVAC/RoSAVA 2014
Blood Pressure
Oscillometric methid makes use of appropriate
sized cuffs and the BP monitor/module
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AMVAC/RoSAVA 2014
Temperature
• Most neglected parameter
• The absolute minimal: measure body temperature of each patient at the end of each anaesthesia
• Better: continuous measurement with esophageal or rectal probe
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AMVAC/RoSAVA 2014
A fine combination
• 1. Capnometry/graphy
• 2. Pulsoximetry
• 3. Elecrocardiography
• 4. Blood pressure
• 5. Temperature
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AMVAC/RoSAVA 2014
Technical monitoring
• Capnography
• Pulse oxymetry
• NIBP
• Temperature
• ECG
• IBP(invasive blood pressure)
• Inhalational gas analyser
• O2 measurement
• Electronic spirometry
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AMVAC/RoSAVA 2014
Monitoring of lung mechanics (compliance and resistance). Spiromety with loop visualisation and compliace calculation
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AMVAC/RoSAVA 2014
Monitoring of lung mechanics
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AMVAC/RoSAVA 2014
Patient
Anaesthetic machine
Technical monitors
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AMVAC/RoSAVA 2014
Clinical Monitoring
• There are no good monitors, there are only anaesthetists you can trust
• Electronic monitoring cannot replace totally clinical monitoring !!!
• The responsable must be familiar with clinical monitoring before focusing on electronic monitoring
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AMVAC/RoSAVA 2014
Clinical Monitoring
• For good anaesthetic management one
must know artefacts for each measured
parameter
• For good management one must be
able to interprete the information
(numbers) provided
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
Presentation 30 years ago
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
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AMVAC/RoSAVA 2014
Questions?