Patient Monitoring in ICU PDF

Patient Monitoring in ICU Monitoring definition # Interpreting available clinical data to help recognize present or future mishaps or unfavorable system conditions Monitoring goals I Enhances (but not replaces) the vigilance of the intensivist. ⑪ Provides means to asse...

Patient Monitoring in ICU Monitoring definition # Interpreting available clinical data to help recognize present or future mishaps or unfavorable system conditions Monitoring goals I Enhances (but not replaces) the vigilance of the intensivist. ⑪ Provides means to assess physiological function. 3 Provides information that improves the safety of patient. Monitoring guidelines - I Qualified personnel should be present in the ICU - Physical examination, Assessment & Diagnosis remain the most important tools available to the intensivist Basic Monitoring 1) Oxygenation is 2) Ventilation cos => 3) Circulation 4) Temperature should be continually evaluated. 1 1) Oxygenation Objective: To ensure adequate oxygen concentration in the delivered gas and => in the blood. Methods -> - - 800 1) Clinical: color, respiratory pattern (rate, rhythm, depth, etc.), equal air entry, wheezing, crackles. 2) Delivered gas: the concentration of oxygen in the patient breathing system - shall be measured by an - oxygen analyzer. 3) Blood oxygenation: a quantitative method of assessing oxygenation such as pulse oximetry shall be employed and ABGs show - PaO2. - 2) Ventilation A. Every patient should have the adequacy of ventilation continually evaluated. 1) Clinical signs such as chest movement and auscultation of breath sounds - = = - are useful. 2) ⑳ * ABGs show PaCO2 > ⑧ * Continual end-tidal carbon dioxide analysis ⑧ * Monitoring of the volume of expired gas is strongly encouraged in mechanically ventilated patients. B. When ventilation is controlled by a mechanical ventilator, there shall be in - continuous use a device that is capable of detecting disconnection of components of the breathing system. The device must give an audible signal. 2  hereasses - - as as 3) Circulation ⑰ Every patient shall have the ECG continuously. =- Every patient shall have BP and HR determined and evaluated at close > = > > intervals. ⑳ & Other clinical evaluation methods like Palpation of a pulse, Auscultation of - -- heart sounds & Oximetry ⑰ Other used monitors: Temperature [pharyngeal, axillary, esophageal] Urine output N.R (0.5m/kg/h) Central venous line: measuring CVP [jaguar, subcam, femeral) Arterial line: – Continuous BP monitoring – Easy access allowing for frequent ABGs Less frequently used monitors: Swan-Ganz catheter, PCWP: pulmonary artery pressures, cardiac output - ICP monitoring branch EEG I Transesophageal echocardiography (TEE) 3  shock I -R & R. fluid nat Vassopresser, Central venous pressure (CVP) is the pressure recorded from the right atrium or superior vena cava and is representative of the #> filling pressure of the right side of the heart? CVP monitoring in the critically ill is established practice but the traditional belief that CVP reflects ventricular preload and predicts fluid responsiveness has been challenged by a large body of evidence CVP represents the driving force for filling the right atrium and ventricle normal is 0-6mmHg in a spontaneously breathing non-ventilated patient =- MEASUREMENT -Her ① right atrum flad & response recorded⑧ at the end of expiration - > measured by transducing the waveform of a central venous line - - - electronic transducer placed & zeroed at the level of the RA (the “hemostatic axis” – usually - the 4th intercostal space in the mid-axillary line is used) - CVP WAVEFORM - R. Sidesigig. of heart * a = atrial contraction c = closing and bulging of the tricuspid valve x = atrial relaxation, with downward movement of the tricuspid valve during ventricular contraction - - v = passive filling of atrium (tricuspid valve still closed) ngwich > y = ventricular filling with opening of the tricuspid valve - fat atwic co y usped Petrol C losi value d From and tion al I W ⑧ = > an USE Value and waveform assist with diagnosis of: -> right ventricular infarction right heart failure and cor pulmonale 4  tamponade ↳55 Tricuspid regurgitation or stenosis Complete heart block ofheart - - -> elegeness vende ↓I Constrictive pericarditis -> CVP sy; dising - Determining: mechanical atrial capture with AV pacing presence of P waves in cases of SVT differential diagnosis of shock state correct central line placement CAUSES OF RAISED CVP Ens I Right ventricular failure Tricuspid stenosis or regurgitation I 3 - Pericardial effusion or constrictive pericarditis ⑪Y Superior vena caval obstruction S Fluid overload S Hyperdynamic circulation -? 1 - High PEEP settings Low Central Venous Pressure ⑳ ⑫ Some factors that can decrease central venous pressure are hypovolemia -- or vasodilation. Either of these would decrease venous return and thus decrease the central venous pressure. A decrease in central venous pressure is noted ⑭ when there is more than 10% of ⑤ blood loss or shift of blood volume. A decrease in intrathoracic pressure caused by forced inspiration causes the vena cava to collapse which decreases the venous return and, in turn, decreases the central venous pressure. CVP WAVEFORM ANALYSIS Waveform abnormalities may indicate specific pathologies: - > ↓38 e e e Dominant a wave – pulmonary hypertension, tricuspid stenosis, pulmonary stenosis ⑰ ⑳ - ⑤S Cannon a wave – complete heart block, ventricular tachycardia with atrio-ventricular dissociation 25 Dominant v wave – tricuspid regurgitation - Absent x descent – atrial fibrillation - - - sys Exaggerated x descent – pericardial tamponade, constrictive pericarditis Sharp y descent – severe tricuspid regurgitation, constrictive pericarditis Slow y descent – tricuspid stenosis, atrial myxoma Prominent x and y descent – right ventricular infarction 5  ETC0-32 s is : ETT as4* Airway / Respiratory Axis Oxygenation Ventilation Correct ETT placement 11s x ETT cuff pressure (keep between 20-30 cm H2O) -> niceration intrachen leak , 81 Is's Airway pressure apnea, 38- 6  Respiratory Monitoring Various alarms by the ventilator: A – Low airway pressure: leakage, disconnection. - - & – High airway pressure: kink, biting of the tube, blocked tube, bronchospasm. -> - - 3 – Low expired tidal volume: leakage. > y – Apnea alarm: disconnection. - S – O2 sensor failure: (unfortunately common in many of our ventilators). - – Flow sensor failure: (unfortunately common in many of our ventilators). 6 - -NEVER ignore an alarm by the ventilator! airway resistanty';jCt 5* PEAK INSPIRATORY PRESSURE (PIP) ⑧ ⑳ Depends on: Airway resistance (Raw) & lung compliance (Cl). During controlled ventilation look for increase airway resistance - (e.g., bronchospasm, kinked ETT) or decrease in pulmonary compliance (e.g., - > = pulmonary congestion). Oxygenation and ventilation Pulse oximetry (vital sign for Oxygenation) – Measures O2 saturation in blood 7  Capnography (vital sign for ventilation &perfusion) – Measures CO2 in the airway – Provides a breath-to-breath status of ventilation Cardiovascular Axis : 1. Arterial Blood Pressure x 2. Electrocardiography 3. Central Venous Catheterization 4. Pulmonary Artery Catheterization 5. Cardiac Output: Thermodilution Dye Dilution Pulse Contour Devices Esophageal Doppler Fick Principle Echocardiography Thoracic Bioimpedance Ell Electrolyte / Metabolic Axis Fluid balance 1. - 4 It Sugar can cause Cardic arrest Electrolytes Acid-base balance 8  Nutritional status Visual Monitoring Respiratory: patient color, respiratory pattern (accessory muscle use etc.) Patient monitor numbers and waveforms Bleeding/coagulation sweating Diaphoresis / movements Line quality (is my IV reliable?) Positioning safety review 9