La presentazione è in caricamento. Aspetta per favore

La presentazione è in caricamento. Aspetta per favore

IL MONITORAGGIO DELLE FUNZIONI VITALI Clinica di Anestesia e Rianimazione Azienda Ospedaliera Universitario - AOU University of Udine. Udine, Italy.

Presentazioni simili


Presentazione sul tema: "IL MONITORAGGIO DELLE FUNZIONI VITALI Clinica di Anestesia e Rianimazione Azienda Ospedaliera Universitario - AOU University of Udine. Udine, Italy."— Transcript della presentazione:

1 IL MONITORAGGIO DELLE FUNZIONI VITALI Clinica di Anestesia e Rianimazione Azienda Ospedaliera Universitario - AOU University of Udine. Udine, Italy

2 IL MONITORAGGIO la storia dietro la storia

3 Human error…... ASA Status

4

5 Inadequate monitoring 10% anesthesia related deaths Postop monitoring: inadequately 8% pts unavailable 5% pts Arbous MS, Grobbee DE, et al. Anaesthesia 2001;56: anesthesia 769 pts died within 24 hours after anesthesia 42 pts comatose

6 Arbous MS, Grobbee DE, et al. Anaesthesia 2001;56:

7 Vital Signs Monitoring Guidelines Cardiovascular Respiratory Others

8 ECG (fino alla dimissione dalla CO) AP non invasiva (Δt<10 min) Ossigenazione: FiO 2, SpO 2 Ventilazione: EtCO 2, Spirometria Respiratore con sistema di allarme acustico Temperatura Trasmissione neuromuscolare Registrazione dei parametri misurati Raccomandazioni SIAARTI Monitoraggio di minima durante anestesia SIAARTI II edizione giugno 1996

9 ASA standards for basic anesthetic monitoring 2001 Standard 1: Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care Standard 2: During all anesthetics, the patient's oxygenation, ventilation, circulation, and temperature shall be continually evaluated

10 Oxygenation: Oxygen analyzer for inspired gases-Observation of the patient Pulse oximetry Ventilation: Auscultation of breath sounds-Observation of the patient Observation of the reservoir bag Capnography (Carbon dioxide monitoring) Circulation: Continuous ECG display Heart rate and BP recorded every 5 minutes Evaluation of circulation Auscultation of heart sounds Palpation of pulse Pulse plethysmography Pulse oximetry Intrarterial pressure tracing Temperature: Monitor temperature when changes are intended, anticipated, or suspected ASA standards for basic anesthetic monitoring 2001

11 Buhre W and Rossaint R. The Lancet 2003; 362:

12 Monitoring recommendations of the Association of Anesthetists of Great Britain and Ireland

13 Buhre W and Rossaint R. The Lancet 2003; 362:

14

15 There is growing evidence that no single monitoring device can improve outcome in the OR or in the ICU.

16 ECG blood pressure pulse oximetry capnography + anesthetic gas concentrations + FiO2 temperature

17 Anesthesiology 2002;96: Immediately available

18 Periop monitoring Guidelines Cardiovascular Respiratory Others

19 EKG Monitor EKG

20 Intraoperative Monitoring invasive - invasive AP Swan Ganz cath PiCCO System Advanced PAC: SVO 2, CCO, REF, EDV …………………TEE

21 Intraoperative Monitoring invasive

22 Intraoperative Monitoring invasive oscill 2-4

23 Arterial pressure A P art t

24 From Less-invasive to non-invasive CO monitoring

25 SPV – SVV - PPV

26 Anesth Analg 2005; 100:

27 Anesthesiology 2002;97: pts ASA I-III major elective surgery Esophageal doppler FTc > 350 msec

28 Anesthesiology 2002;97:820-6

29 for pts undergoing moderate and high-risk surgery, goal-directed fluid administration with 6% hetastarch is associated with improved pts outcome and a slight reduction in LOS Anesthesiology 2002;97:820-6

30 Cardiac output Invasive Less invasive Non invasive Pulmonary Artery Catheter (PAC) thermodilution (TD) + advanced Continuous vs Intemittent CO

31 Periop monitoring Guidelines Cardiovascular Respiratory Others

32 Fi -FeO 2 Fi-Fe volatile an. SpO 2 EtCO 2 AwP (peak-plateau) Peep compliance P/V e flow slope Respiratory monitoring

33 Fi -FeO 2 Fi-Fe volatile an. SpO 2 EtCO 2 AwP (peak-plateau) Peep compliance P/V e flow slope

34 PULSOXIMETRY

35 During observation in the recovery room, the incidence of hypoxemia in the pulse oximetry group was time less.

36 Fi -FeO 2 Fi-Fe volatile an. SpO 2 EtCO 2 AwP (peak-plateau) Peep compliance P/V e flow slope

37 EtCO 2 CAPNOGRPHY Time in sec mmHg

38 Tetevossian RG, Wo CC, Shoemaker WC. Crit Care Med 2000;28: pts whit blunt and hemodynamic instability

39 Tetevossian RG, Wo CC, Shoemaker WC. Crit Care Med 2000;28: PtcO 2 and PtCO 2 early indicators of tissue hypoxia, subclinical hypovolemia, and hemodynamic shock in ER severely ill patients. Ptc-gas values reflect local skin perfusion during normal conditions and in period of circulatory dysfunction and shock.

40 Periop monitoring Guidelines Cardiovascular Respiratory Others: Temperature Depth of GA NMT Glycemia Lactate

41 Kurz A, Sessler I, Lenhardt R. NEJM 1996;334: pts elective colon surgery Normotermia 37±0.3 °C Ipotermia 34.4±0.4 °C Intraoperative core temperatures approximately 2°C below normal triple the incidence of wound infection and prolong hospitalization by about 20%.

42 TEMPERATURE

43 Periop monitoring Guidelines Cardiovascular Respiratory Others: Temperature Depth of GA NMT Glycemia Lactate

44 BIS…..PSA 4000 and AEP

45 BIS HYPNOSIS STATE Awake / moderate sedation Mild hypnosis state Low probability of awareness < 70 Moderate hypnosis state Not awareness <60 Deep hypnosis state EEG suppression

46

47

48 13 AWARENESS: 11 CTRL 2 BIS

49 49 Possible AWARENESS: 27 CTRL 22 BIS

50

51 Conclusions: BIS cost = 16USD To prevent 1 case of awerenwss: 2200 USD

52 Periop monitoring Guidelines Cardiovascular Respiratory Others: Temperature Depth of GA NMT Glycemia Lactate

53 TOF WATCH NMT MONITORING IN ANESTHESIA Reversal: M.R. Chelant

54 Residual neuromuscolar block is a risk factor for postoperative pulmonary complication. Berg H, Viby-Mogensen J, Roed J et al. Acta Anaesthesiol Scand 1997;41: pz PANC-ATR-VEC Intraop TOF ogni 12 sec Postop TOF+Meccanomiografia Postop Pulm Complications ch generale maggiore >durata età PANC se TOF

55 Anesthesiology 2003;98(5): pz VEC-ROC-ATR No reveral

56 Anesthesiology 2003;99(3): hour nmol/kg/min ROC c.i. in guinea pigs after 30 min Org c.i 50 nmol/kg/min o NS

57 Periop monitoring Guidelines Cardiovascular Respiratory Others: Temperature Depth of GA NMT Glycemia Lactate

58 Risposta allipoglicemia Splachnic perfusion

59 Risposta alliperglicemia

60 Anesthesiology 2003; 98:

61

62

63 Periop monitoring Guidelines Cardiovascular Respiratory Others: Temperature Depth of GA NMT Glycemia Lactate

64 Gladden JB. J Physiol 2004; 558: 5-30 Lactate metabolism: a new paradigm for the third millenium Tissue hypoperfusion, hypoxia and resulting anaerobic glycolysis are probably not the only causes of increased La - production during shock Lactate plays an important role as intermediatory in numerous metabolic process, a mobile fuel for aerobic metabolism, perhaps a mediator of redox state among various compartment both within and between cells

65 Gladden JB. J Physiol 2004; 558: 5-30 Lactate metabolism: a new paradigm for the third millenium Lactate can no longer be considered the usual suspect for metabolic crimes, but is instead a central player in cellular, regional and whole body metabolism

66 Anesth Analg 2002; 95: 294-8

67 CONCLUSIONS

68 Cartella computerizzata di Anestesia /T.I. Collegamento ad un server

69 Acquisizione : On line Trends Snap Shots

70 Vital signs monitoring: When ? Where ? How ? Why ? type of surgery and pt condition OR and/or ICU / PACU / Ward …….. several techniques to manage….to improve outcome

71 ASA News Letter 2002

72 Conclusioni: Lessenziale ed il superfluo


Scaricare ppt "IL MONITORAGGIO DELLE FUNZIONI VITALI Clinica di Anestesia e Rianimazione Azienda Ospedaliera Universitario - AOU University of Udine. Udine, Italy."

Presentazioni simili


Annunci Google