dr. radhika dhanpal [email protected] professor and head department of anesthesiology...
TRANSCRIPT
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Dr. Radhika Dhanpal
Professor and Head
Department of Anesthesiology and Critical Care,St. John’s Medical College Hospital
Bangalore
www.anaesthesia.co.in Email: [email protected]
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ASA House of delegates July 1, 2011 implementation of Oct 2010 decision “Standards for Basic Anesthesia Monitoring”During regional anesthesia (with no sedation ) or local anesthesia (with no sedation ), the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs. During moderate or deep sedation, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled CO2 unless precluded or invalidated by the nature of the patient, procedure or equipment”
ISA – Desirable standard 1999
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Definition : Graphic display of instantaneous CO2 concentration
LuftCollier RamwellHolland in 1978 , was the first country to adopt it as a
standard of monitoring during anaesthesia .
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Capnometer The machine Capnography Wave form
Capnometry Numerical Valve
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Methods of measurement
Infrared spectrography
Raman spectrography
Mass spectrography
Photoacoustic spectrography
Chemical colorimetric analysis
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Raman spectrography
Gas sample is aspirated into the analysing chamber where it is illuminated by a high intensity monochromatic argon laser beam. The light is absorbed by molecules which are then excited to unstablevibrational or rotational energy states, these Raman scattering signals are then measured.
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Mass spectrography
It separates gases and vapors of different molecular
weight on the basis of their mass into a spectrum. By
analyzing the spectrum, the composition and relative
abundance of each gas in a sample can be determined .
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Infrared method :
Infrared waves at 4.3 mm are absorbed by certain gases producing absorption bands on the infrared electromagnetic
spectrum.
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Photoacoustic gas measurements
The gas to be measured is irradiated by modulated light of a pre-selected wavelength . The light beam when chopped, generates an acoustic signal which is detected by two microphones.
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Colorimetric method
Chemically treated foam indicator attached to endotracheal tube.
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Factors influencing the reading ;
a) Atmospheric pressure : Changes in atmospheric pressure are usually of the order of 20 mm Hg . This results in a change in PaCO2 of less than 0.5 - 0.8 mm Hg
b)PEEP .c) Water vapour : Can condense on the sensor cell and produce falsely
high readings. This may be prevented byHeating sensor above body temperature sampling tube can be made of a semipermeable polymer that allows
water vapour to pass outside.Absorbent filters.
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TYPES –IIMain stream capnography
Disadvantages : Heavy Hot Window to be kept clean
Advantages : Faster No gas is removed No uncertainity by rate of gas sampling
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Calibration :
Periodically
Gas of known CO2 concentration
Calibration cells with mixtures of CO2 and N2 are available.
Sampling tube should be the same type as the one used on the patient.
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Type of capnogram
Time capnogram
Volume capnogram
Fast 7mm/sec
Slow 0.7 mm/sec
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Time capnogram
Inspiratory segment Expiratory segment
Alpha angle
Beta angle
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Phase I No CO2 Anatomical and apparatus dead space gas Phase II Rising CO2 Mixing of dead space gas and alveolar gas.Phase III Static or
rising CO2Alveolar gas
Phase IV Falling CO2
Beginning of inspiration
α angle - 100-110º ; Airway Obstruction causes larger angle. β angle - 90º ; Rebreathing increases the angle.
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Volume capnogram
Advantage s• Volume of CO2 per exhaled breath can be measured • Significant changes in the morphology of the expired wave form can be detected • Dead space can be partitioned Disadvantages • Intubation mandatory • Elaborate equipment• Only monitors expiration
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Interpretation of the waveform
Height
Frequency
Rhythm
Baseline
Shape
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PaCo2 – PEtCo2-1
Normal 2-5 mmHg
Increased Decreases
Age Large TV
Pulmonary disorders Low Frequency Ventilation
PE Pregnancy
CO Infants
Hypovolemia
Anaesthesia
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CO2 insufflation ( peritoneum , Pleura , joint )
Metabolic PaCo2 – PEtCo2-2
Increase DecreaseHyperpyrexia HypothermiaShivering Increased Muscle relaxation ConvulsionsBlood /NaHCO3 administration Release of an arterial clamp/tourniquetDextrose containing fluidsParenteral hyperailmentation
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PaCo2 – PEtCo2-3
Circulatory Increase Decrease
Epinephrine injection CO
CPR • Surgical manipulations of the heart, great vessels, wedged PAC, PE• Air Embolism
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Uses Anaesthesia
Verification of tracheal intubation Assist in blind oral or nasal intubation Needle cricothyroidotomy Jet stylet introducer Fiberoptic bronchoscopy Double lumen tube placement Monitoring of spontaneous ventilation Curare cleft HFJV Detection of circuit leaks Detection of malfunction of valves or faulty anaesthetic system.
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Critical Care
CPCRDetermine the needs during mechanical ventilation WeaningPlacement of NG tube
Others
PACUPatient transferPost operative ward Procedural sedation Apnea test for brain death Emergency Department
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REBREATHING WITH ELEVATED BASELINE
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ESOPHAGEAL INTUBATION WITH CARBONATED BEVERAGES IN STOMACH
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CO2 ABSORBENT EXHAUSTION
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ESOPHAGEAL INTUBATION
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ESOPHAGEAL INTUBATION FOLLOWING MASK VENTILATION.
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EXPIRATORY VALVE MALFUNCTION
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SPONTANEOUS BREATHING
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NORMAL WAVEFORM
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CURARE CLEFT
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AIR LEAK
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HYPERVENTILATION
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CONTAMINATION OF
CO2 SENSOR
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CARDIAC ARREST,SUCCESSFUL RESUSCITATION
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HYPOVENTILATION
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BRONCHOSPASM
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IMV WITH INTERPOSED SPONTANEOUS RESPIRATION.
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CARDIOGENIC OSCILLATIONS (RIPPLE
EFFECT)
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INSPIRATORY VALVE
MALFUNCTION
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POST SINGLE LUNG TRANSPLANTATION.
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BAIN CIRCUIT/MAPELSON D (SIGNATURE CAPNOGRAM)
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