Clinical Measurement and Equipment
Clinical Measurement and Equipment
Clinical Measurement and Equipment
Problems in interpretation
· Pulse oximetry does not detect respiratory failure. A high F1o2, may mask
Ventilatory 'failure by ensuring high SPO2% readings.
· In very anaemic patients Spo2% readings may show high saturations although
oxygen delivery to the tissues may be impaired.
Describe the physical principles which underlie the function of a
'Rotameter' flowmeter. What factors may lead to inaccuracies in its use?
There are few anaesthetics given which do not involve the use of at least one
'Rotameter' flowmeter. ('Rotameter' is a tradename which continual use has
given the status of a generic object.) It is important, therefore, to be aware of how
they function as well as of potential sources of inaccuracy.
Introduction
it would be unusual to find many anaesthetics, either general or local, which do
not involve the administration of at least oxygen via a 'Rotameter'. 'Rotameter'
is the tradename for a variable-orifice, fixed-pressure-difference flowmeter,
which gives a continuous indication of the rate of gas flow.
Physical principles
· A bobbin floats within a vertical conical glass tube, supported by the gas
relation to the bobbin and the flow is turbulent. Flow rate is related to the
density of the gas and the square of the radius.
· These factors mean, therefore, that 'Rotameters' have to be calibrated for the
specific gases that they are measuring and are not interchangeable for
different gases.
· The pressure across the bobbin at any flow rate remains constant, because
the force to which it gives rise is exactly balanced by the force of gravity acting
on the bobbin.
Other features
· The bobbin is designed with small slots or fins in its upper part so that it will
rotate centrally within the gas stream. This is to prevent it sticking to the side
of the tube because of dirt or static electricity.
· To prevent the accumulation of static charge tubes have either a conductive
features above.
· Flowmeter block that is not vertical: the bobbin must not impinge on the sides
of the tube.
· Back pressure on the gas flow may still be a problem on some anaesthetic
machines.
· Cracked seals or tubes may provide a source of error.
How does a capnometer or capnograph measure CO2 concentration?
What useful information is conveyed by the capnogram (the graph
of CO2 against time)?
Together with pulse oximetry, capnography is regarded by most anaesthetists to
be indispensable. Some believe it to be more useful than oximetry because of
the large amount of information that can be obtained from an end-tidal CO 2
reading and a capnograph trace. This question aims to explore whether you are
aware of the clinical information that can be obtained during routine CO 2
monitoring.
Introduction
Capnography has the potential to convey a large amount of vital clinical
information about both the respiratory and cardiovascular status of a patient,
and for this reason there are many anaesthetists who believe it to be the single
most useful form of monitoring in anaesthetic practice.
Physical principles
· Most capnographs measure CO2 by means of infra-red absorption. A molecule
identification. There is some overlap between CO2 and N20 for which
modem instruments can compensate, collision broadening would otherwise
elevate falsely the CO2 readings.
Clinical information
No CO2 trace:
- Oesophageal intubation. Its use is mandatory wherever tracheal
intubation is used.
- Disconnection of breathing system.
- Tracheal tube displacement.
- Cessation of CO2 production due to circulatory arrest.
Low or falling end-tidal CO2:
- Hyperventilation. May be due e.g. to pain or inadequate anaesthesia in a
spontaneously breathing patient, or to over-ventilation in IPPV.
- Pulmonary embolism (gas or thrombus). Sudden fall of CO2 excretion due
to compromise of the pulmonary circulation.
- Decreased cardiac output, hypoperfusion, shock.
Normal end-tidal CO2:
— Adequate ventilation.
High or rising end-tidal CO2:
— Inadequate ventilation.
— Rebreathing (this may just increase the baseline which does not return to zero).
— Soda lime exhaustion.
— Malignant hyperpyrexia or other hypermetabolic state in which CO2
production increases.
Abnormal capnography wave forms:
- Slow upstroke and slowly rising plateau: indicates chronic or acute
airway obstruction (this may be lower or upper airway as well as in the
breathing system).
- Inspiratory dips in the wave form: indicates partial recovery from
neuromuscular blockade.
- Raised baseline: rebreathing as above.
How can jugular venous bulb oxygen saturation be measured?
What is the purpose of this investigation? What factors cause it
to increase or decrease?
This is an area of specialist practice which you may not have encountered. If you
are struggling the answer is best developed from first principles.
Introduction
Jugular venous oxygen saturation (Sjvo2) provides a measure of global cerebral
oxygenation and finds uses in neurosurgery, in neurotrauma and in cerebral
monitoring during cardiac surgery.
Measurement
· Sjv 02 is usually measured via an intravascular catheter threaded retrogradely
up
the internal jugular vein as far as the jugular bulb. Normal value is 55-75%.
· A fibreoptic catheter uses reflectance oximetry (as in PA monitoring of mixed
and is verified by lateral skull X-ray which should confirm the tip lying at the
level of, and medial to, the mastoid process.
Alternatively a sample may be taken directly from the jugular bulb and the
oxygen saturation measured by co-oximetry.
Factors which change Sjvo2
· Sjvo2 is an indirect indicator of cerebral oxygen utilization: when o 2 demand
exceeds supply then extraction increases and Sjvo2 falls (desaturated at
<50%), conversely when supply exceeds demand it rises (luxuriant at >75%).
It is a specific measure of global cerebral oxygenation but is not sensitive to
smaller focal areas of ischaemia.
· The difference in oxygen content between arterial and jugular venous blood
(AjvDO2) is given by CMRO2 (cerebral metabolic rate for 02)/CBF (cerebral
blood flow). Normal is 4-8 ml 02/ 100 ml of blood.
· If AJVDo2 is <4 supply is luxuriant: if >8 it suggests ischaemia
· Increased oxygen demand or decrease in supply (fall in SJVo2 and rise in
Appo,) results from:
- Raised ICP.
- Systemic hypotension (severe).
- Hypocapnia (<3.75 kPa).
- Arterial hypoxia.
- Cerebral vasospasm.
— Increased metabolic demand: pyrexia, seizures.
· Decreased oxygen demand or increase in supply (rise in Soo, and fall in Afrood
results from:
- Decreased metabolic demand (hypothermia; sedation).
- Increased blood supply.
- Hypercapnia.
- Arterial hyperoxia.
- Brain death (minimal demand).
Explain the basic principles of surgical diathermy. What are its
potential problems?
Diathermy is used very widely in surgical practice but it does have
implications for the anaesthetist, who will be blamed, unfair though it may
seem, should a patient suffer a burn due to malpositioning of the plate.
Diathermy may also interfere with monitors and can disrupt pacemaker
function and so is a topic on which some basic knowledge is expected.
Introduction
Diathermy is used widely in surgical practice, both for coagulation and for
cutting, and relies on the heating generated as an electric current passes
through a resistance that is concentrated in the probe itself.
Principles of action
►Heat generation is proportional to the power that is developed: typically
50-400 W.
► high frequency sine waveform is used for cutting: typically 0.5 MHz.
► A damped waveform is used for coagulation: typically 1.0-4.5 MHz.
►High frequency is necessary because muscle is very sensitive to direct current
and to alternating current at frequencies less than –10 kHz. This is
particularly important in relation to myocardial muscle: low frequencies may
precipitate fibrillation.
►Burning and heating effects can occur at all frequencies.
Types of diathermy
· Unipolar. There are two connections to the patient: the neutral (or indifferent)
patient plate, and the active coagulation or cutting electrode. Current passes
through both but the current density at the active electrode is very high and
generates high temperatures. At the patient plate the current density is
dispersed over a wide area and heating does not occur. The patient plate and
hence the patient is kept at earth potential, which reduces the risks of
capacitor linkage (in which diathermy current may flow in the absence of
direct contact). Modern diathermy machines incorporate isolating capacitors
to minimise the problem. An alternative is to use an earth free or floating
circuit.
* Bipolar. Current is localised to the instrument: it passes only from one
blade of the forceps to the other. Bipolar diathermy uses low power, and
this limits its efficacy in the coagulation of all but small vessels. The circuit
is not earthed.
Problems
Thermal injury at the site of the indifferent electrode (the diathermy
plate) which must be in close and even contact with a large area of skin,
ideally an area that is well perfused and which will dissipate heat.
Adhesive and conductive gels are useful. If the area of contact is small
the current density increases to the point at which a burn is probable.
Thermal injury at metal contact site if plate is detached or malpositioned.
The diathermy current may flow to earth through any point at which the
patient is touching metal (operating table, lithotomy poles, ECG
electrodes, etc.) and cause a burn.
Activation of instrument when it is not in contact with the tissue to be
cut or coagulated.
Circuit may be completed via a route that does not include the
indifferent electrode: may result in a burn.
Alcoholic skin preparation solutions have ignited after diathermy
activation.
Interference with pacemaker function (indifferent electrode should be
sited as far distant as possible and bipolar should be used if possible).
Diathermy may lead to ischaemia and infarction of structures supplied
by fine end-arteries. Classic examples include the penis (hence unipolar
must be avoided. in circumcision) and the testis which has a
vulnerable vascular pedicle.
Outline ways of measuring humidity and evaluate the methods by
which gases can be humidified in clinical practice. Why is this
important?
Anaesthesia frequently involves bypassing sites in the upper airway that are
responsible for the humidification of inspired gases. Artificial humidification is
important in the context both of anaesthesia and intensive care, and so you
will be expected to know about the different methods that are commonly
used.
Introduction
The mass of water vapour that is present in a given volume of air (the
absolute humidity) varies with temperature so that at 20°C fully saturated air
contains 17 g m-3. By the time that it reaches the alveoli at 37°C this air is
fully saturated and contains 44 g m-3. Anaesthetic and medical gases,
however, are dry and may bypass the normal humidification mechanisms.
Measurement
· Hair hygrometer. The hair, which is linked to a spring and pointer,
Methods of humidification
· HME (heat and moisture exchange) filter. This is a widely used method,
which is passive, and which cannot, therefore, attain 100% efficiency, but
which may reach 70-80%. The HME contains a hygroscopic material within a
sealed unit. As the warm expired gas cools so the water vapour condenses on
the element, which is warmed both by the specific heat of the exhaled gas and
the latent heat of the water. Inhaled, dry and cool gas is thus warmed during
inspiration, during which process the element cools down prior to the next
exhalation. Problems include moderate inefficiency in prolonged use,
increased dead space, infection risk.
· Water bath (cold). Passive, in that dry gases bubble through water at room
crusting of secretions.
· Mucus plugging, atelectasis, superimposed chest infection, impaired gas
exchange.
Patients at risk
· Those undergoing prolonged anaesthesia.
and side guards on each yoke ensure that the cylinders are vertical.
· Bourdon pressure gauge indicates cylinder pressure.
· Pressure regulator/ reducing valve reduces pressure to 4 bar, and a relief valve
threads are gas specific (NIST – non-interchangeable screw thread) and a one-
way valve ensures unidirectional flow.
Flow restrictors
Placed upstream of the flowmeter block and protect the low-pressure part of
the system from damaging surges in gas pressure from the piped supply.
May sometimes be used downstream of vaporiser back bar to minimise
back pressure associated with IPPV.
Oxygen failure devices
· Systems vary. In one example a pressure sensitive valve closes when 02 pressure
falls below 3 bar, and the gas mixture is vented, activating an audible warning
tone. The same valve opens an air-entrainment valve so that the patient cannot
be exposed to a hypoxic mixture resulting from failure of 0 2 delivery.
Flow control valves
These govern the transition from the high to the low pressure system.
Reduce the pressure from 4 bar to just above atmospheric as gas enters the
flow Meter block.
An interlock system between 02 and N20 control valves prevents N20
administration of >75%.
Flowmeters
Constant pressure variable orifice flowmeters, calibrated for specific gas.
Antistatic coating to prevent sticking, vanes in bobbin to ensure rotation
Oxygen knob in UK is always on the left, is larger, is hexagonal in profile
and is more prominent than the others (this position risks hypoxic mixture
if there is damage to a downstream flow meter tube).
CO2 has disappeared from many machines: where it is still delivered it is
usually governed to prevent a flow >500 ml min-1.
Vaporisers and back bar
· Most common is temperature-compensated variable bypass device to allow
time.
· Non-return valve on back bar prevents retrograde flow (the pumping effect of
IPPV).
· Pressure relief valve on downstream end of back bar protects against increases
block and provides 35-75 L mirr' (if the 0, flowmeter needle valve is opened
fully it delivers - 40 L
· Both methods may cause barotrauma in vulnerable patients.
normal but the blood supply to tissues is inadequate due to diminished cardiac
output or occlusion of the peripheral vascular'system.
· Anaemic hypoxia. Pao2 is normal but low haemoglobin reduces 02 carriage
— Placed upstream of the flowmeter block and protect the low-pressure part of
the system from damaging surges in gas pressure from the piped supply.
· Flow control valves
— These govern the transition from the high to the low pressure system.
Reduce the pressure from 4 bar to just above atmospheric as gas enters
the flowmeter block.
— Needle valves restrict flow.
· Vaporisers and back bar
— Closes during inspiratory phase of IPPV and vents gas after bellows refills.
Should it stick in the dosed position the will increase.
· Scavenging system
— A pressure relief valve in system vents excess gas in reservoir to atmosphere. If
this valve fails then pressure is transmitted back to the breathing system.
· Breathing system and airway
What are the main postoperative problems which occur in the first 24 hours
following a coronary artery bypass graft? Outline their management.
Coronary artery bypass grafting (CABG) is a common procedure in the developed
world, but although it has become routine there remain a large number of
potential complications, many of them related to cardiopulmonary bypass (CPB),
which can affect every organ system. The question is testing your appreciation of
the main principles rather than specifics. If you are struggling then it may help to
consider the worse case scenarios, given the huge array of complications of CPB
that have been described.
Introduction
Surgery for coronary artery disease involves the insertion of a vascular graft in
an organ which may have precarious function. The surgery may be prolonged
and is enabled by the use of cardiopulmonary bypass, which as a non-physiological
process has been associated with a large number of complications. There are,
therefore, several problems which may occur in the first postoperative day.
Cardiovascular
· Cardiac failure. Cardiac output may be compromised because of pre-existing
perfusion with oxygen-enriched blood from which CO2 has been removed.
· Components include:
— Venous line (usually from vena cavae) drains into a reservoir for gas
exchange in which blood is oxygenated and CO2 is removed.
- Bubble oxygenator in which 02 is bubbled through the perfusate (cheap,
simple, but requires defoaming to reduce air emboli and damages formed
blood components).
Membrane oxygenator in which gas exchange takes place across a semi-
permeable membrane (fewer emboli form and less damage to RBCs).
- Arterial line (usually to ascending aorta) via a pump (roller or centrifugal):
flow may be non-pulsatile or pulsatile (no proven benefit).
_ Pump for cold cardioplegic solution (contains potassium for EMI) arrest,
energy substrate for metabolism).
_ Ventricular drain to vent heart: may get some aortic regurgitation if not
prevented by aortic cross-clamp, or flow through bronchial and thebesian
veins. May overdistend LV and cause critical ischaemia and post-bypass
dysfunction.
— Filters (27 micron) on both sides of the circulation to remove air and blood
micro-emboli (also reduce platelets).
- Heat exchanger is crucial part of the system to allow temperature control
(hypothermia reduces oxygen demand by 6-9% per °C fall in core
temperature).
- Priming: the system (volume 1.5-2.5 L) is primed either with crystalloid or
colloid/ crystalloid. Acute haemodilution is inevitable as soon as bypass is
established. Can prime with blood if necessary to maintain haematocrit at
20-25%.
- Anti-coagulation. Crucial. Coagulation within any part of the circuit (pump
or patient) is lethal. Synthetic surfaces of circuit cause diffuse thrombosis
and oxygenator failure if anticoagulation is inadequate.
· Complications of circuit;
— Arterial side: cannula may kink, block or fail to deliver adequate flow.
— Venous side: low return: bleeding, obstruction, air lock, aortic dissection.
— Oxygenator failure.
— Pump may cause aortic dissection.
conventional tracheal tube, and are more complex to insert. Different tubes
require different insertion techniques but in all cases there is rotation within
the airway of between 90° and 180°.
· Length of tube. Correct insertion defines the situation in which the upper
surface of the bronchial cuff is immediately distal to the bifurcation of the cw:na.
The distance can be measured. The average depth of insertion for a patient of
height 170 cm 's 29 cm, and the distance alters by 1 cm for every 10 cm change
in height. This distance from the incisors can therefore be used as a guide.
· Auscultation (both lung fields). With both tracheal and endobronchial cuffs
inflated, check bilateral and equal air entry (allowing for pulmonary pathology).
· Auscultation (alternate lung fields). Clamp one side and check that breath
bag will reveal whether it has normal compliance (again allowing for pulmonary
pathology).
· Monitoring: oximetry and, particularly, capnography when compared from
effusion.
· Routine use of ftbreoptic bronchoscopy is the only way of avoiding these
problems and ensuring accurate positioning as well as intraoperative checking if
indicated. It also minimises the complications of DLEBT placement as outlined
below.
may reduce shunt from -50% down to 30% (which is still significant).
· The dependent lung loses volume because of compression, and hypoxic
ml kg-': higher volumes increase Paw and vascular resistance so more blood
may flow to the non-ventilated lung and increase shunt. Lower volumes may
cause atelectasis.
• Although shunt is not substantially improved by supplemental 02 the F1o2 is
usually increased to 0.8-1.0.
· The respiratory rate is adjusted to keep Paco 2 at -40 mmHg (5.3 kPa).
Management of hypoxia
· Check F1o2, and increase if necessary (but may not help if substantial shunt is
the problem).
• Check tidal volume and ventilator indices.
• Check double-lumen tube position with fibreoptic bronchoscope (displacement to
a suboptimal position is common).
•Maintain at -5.3 kPa as hypocapnia may decrease hypoxic pulmonary
vasoconstriction.
•Add CPAP to upper lung (-5 cmH2O) and warn surgeon that lung may partially
re-expand.
• Add PEEP to lower lung (-5 cm1-120) to increase volume in potentially
atelectatic areas — but note that this may increase vascular resistance and
divert blood to upper lung.
•Increase both CPA? and PEEP in small increments.
•If none of these manoeuvres works it may be necessary to revert to full
double-lung ventilation (with retraction to allow surgery to continue