MONITORING OF

ANAESTHESIA
Submitted by- Praney Slathia
Reg. No.- L-2020-V-29-M
ANESTHESIA
Anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical
purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness.

It provides ease of rendering surgical treatment by manipulation of tissue.

Purpose of Monitoring

To maintain adequacy of
◦ CNS depression
◦ Analgesia
◦ Muscle Relaxation
◦ Immobility
Parameters to Observe

◦ Vital Signs
◦ Reflexes
◦ Other Indicators
 Two Important Managemental Issues

Safety of Patient
◦ By maintaining vital signs in limit
Anesthetic Depth
◦ By observing reflexes
◦ To prevent premature arousal or overdose
 Vital Signs
1. Haemostatic mechanisms to anesthesia including Cardiovascular and Respiratory
Responses
2. HR
3. Rythm
4. RR and Depth
5. MM Color
6. CRT
7. Pulse Strength
8. Blood Pressure
9. Temperature

Difficult to measure the depth of Anesthesia with vital signs. Primarily observed to ensure patient
safety.
Reflexes

◦ Involuntary responses to stimulus

◦ Palpebral
◦ Corneal
◦ Pedal
◦ Swallowing
◦ Laryngeal
◦ PLR (pupillary light reflex)
Other indicators for depth

◦ Spontaneous Movement
◦ Eye position
◦ Pupil size
◦ Muscle tone
◦ Nystagmus
◦ Salivary and Lachrymal secretions
◦ Response to Surgical stimulus
Anesthetic Stages and Planes
◦ Stage I - Voluntary Excitement
◦ Stage II - Involuntary Excitement
◦ Stage III – Stage of Surgical Anaesthesia
◦ Light Anesthesia
◦ Surgical Anesthesia
◦ Deep Surgical Anesthesia
◦ Stage III – Stage of Surgical Anaesthesia
There is considerable variation based upon the subject’s physical status as
well as the nature of the surgical operation to be conducted
.
Anesthetic Stages and Planes with Vital
Signs
Key Points
◦ Loss of consciousness marks the border between stages I and II.
◦ Loss of spontaneous muscle movement marks the border between stages II and III.
◦ Loss of all reflexes, widely dilated pupils, flaccid muscle tone, and cardiopulmonary collapse mark
stage IV.

Our goal is stay in the sweet spot of anesthesia that prevents arousal during procedure and does not confer
failure of vital systems, particularly the Cardiovascular and Respiratory Systems.
VITAL SIGNS
1. Indicators of Circulation
2. Indicators of Oxygenation
3. Body Temperature
Indicators of Circulation
1. Heart Rate
2. Heart Rhythm
3. Capillary Refill Time
4. Blood Pressure
Heart Rate
◦ Physically by palpation of apical pulse in the thoracic wall
◦ Palpation of peripheral pulse
◦ By auscultation using a Stethoscope
◦ By Esophageal Stethoscope

◦ Mechanically by an Electrocardiograph, Doppler Flow detector or

Oscillometric Monitor or an Intra-arterial line attached to a transducer.
 Auscultation via Stethoscope
◦ Hard to observe because
◦ Force of contraction falls under anesthesia
◦ Heart position alters because of the relaxation
of muscles and recumbency, therefore observed
on the dependent side
◦ Bradycardia signifies the effect of
anesthetic depth and tachycardia signifies
improper depth, arousal or pain.
 Oesophageal Stethoscope
◦ Simple, reliable and inexpensive method
◦ Catheter after lubrication placed in the oesophagus which shows the reading on a monitor
◦ Beats can be heard after sounds being amplified
Electrocardiography
◦ Based upon the electric stimulus generated by the
cardiac conduction system.
◦ Showcases Realtime status of the heartbeat
◦ Since it helps in judgement of the cardiac rhythm as
well therefore essential tool to rectify cardiac
arrhythmia which is a common occurrence under
anesthesia
◦ Animal is positioned in the right lateral recumbency
for ECG and most commonly Lead II
Capillary Refill Time
◦ It is the rate of return of the
perfusion in the oral mucous
membranes on application and
removal of the gentle pressure.
◦ It is a good method to judge the
peripheral perfusion, which is
decreased if the CRT exceeds 2
seconds.
◦ This fall can be attributed to the
release of epinephrine
◦ It also signifies fall of BP due to
anesthetic administration,
hypothermia, cardiac failure,
excessive depth or shock.
Blood Pressure
◦ BP is the force exerted by flowing blood on arterial walls.
◦ This monitoring parameter is used during anesthesia to evaluate tissue perfusion.
◦ Blood pressure variation
◦ Systolic BP
◦ Diastolic BP
◦ Mean Arterial Pressure (MAP)
◦ MAP is the average pressure through the cardiac cycle and is the most important value from the anesthetist’s
standpoint because it is the best indicator of blood perfusion of the internal organs.
◦ Its value ranges between 60 and 150 mmHg, in which its falling below 60 mmHg has grave consequences.
Pulse Strength
◦ Pulse strength is a physical parameter that can be used as a rough
indicator of BP.
◦ It is assessed by palpating a peripheral artery in one of several locations.
◦ Peripheral arteries appropriate to assess pulse strength include the
lingual (dogs only), femoral (small animals and small ruminants only),
dorsal pedal
◦ It has high individual variation.
◦ Also since strength is the difference between systolic and diastolic
pressures, the MAP picture may not be clear merely based upon the
pulse strength.
BP Monitoring
◦ Generally is either Direct or Indirect
◦ Direct monitoring involves a Transducer (Sensor)
placed in an artery and a monitor.
◦ Generally placed in Pedal or Dorsal Femoral artery by
surgical cut down and percutaneous insertion technique.
◦ Continuous reading and more accurate than the indirect
method.
◦ In general practice, indirect monitors are most
commonly used to measure BP. There are two basic
types of indirect monitor, Doppler and oscillometric,
both of which use a cuff to occlude and release
blood flow sequentially in a major artery of a limb or
the tail.
Doppler Blood Flow
◦ The Doppler blood flow detector is a monitoring device that
consists of an ultrasonic probe and an electronic monitor.
◦ The Doppler probe contains a crystal that emits ultrasound
frequency waves and another crystal that receives the returning
echoes. Outgoing waves bounce off red blood cells (RBCs)
traveling inside a pulsating artery and return to the probe, where
they are sent to an electronic monitor for processing.
◦ The monitor converts the returning echoes into a “whooshing”
sound audible via speaker or earphones.
Oscillometric BP Monitors
◦ An oscillometric BP monitor (oscillometer) consists of a
cuff with an internal pressure-sensing bladder,
connected to a computerized monitor.
◦ The machine inflates and deflates the cuff, and the
computer measures the oscillations in intracuff pressure
caused by the subtle volume changes of the extremity
resulting from pulsations of the artery beneath the cuff.
◦ It then calculates the systolic, mean, and diastolic
pressures, and the HR from the pressure changes.
◦ Oscillometers are more expensive than Doppler devices
but offer two significant advantages: they work
automatically, and they determine the PDIA and MAP
in addition to PSYS
Central Venous Pressure
◦ CVP is the BP in a large central vein such as the anterior vena cava, allows to assess blood return to the
heart and heart function.
◦ Helpful in monitoring animals for right-sided heart failure because it can detect the increased pressure in the vena
cava that results from this condition.
◦ It is also useful in preventing overhydration in animals receiving IV fluids, because CVP values rise when blood
volume is excessive.
◦ CVP can be directly measured by inserting a long catheter percutaneously into the jugular vein or by
cutting down into the jugular vein.
◦ The catheter is advanced into the anterior vena cava and toward the heart so that the tip of the catheter
lies close to the right atrium.
◦ Normal CVP in dogs and cats is less than 8 cm H2O.
◦ Pressures over 12 to 15 cm H2O (taken during exhalation) are considered elevated.
Indicators of Oxygenation
1.Mucous Membrane Color
2.Pulse Oximetry
3.Blood Gas Analysis
Mucous Membrane Color
◦ Shows the level of oxygenation in the tissue
◦ Normally appears Bubblegum Pink
◦ Commonly observed in gingiva
◦ Penile, vulvar, conjunctival and lingual mucous membranes can
also be observed.
◦ Abnormally appears pale in case of intraoperative blood loss, or
may appear cyanotic in low oxygenation of blood because of
respiratory or pulmonary failure.
Pulse Oximeter
◦ Saturation of hemoglobin as percentage of total binding
sites.
◦ It detects Oxygen Saturation as well as the HR
◦ Red- and infrared-wavelength light emitted by the probe
is passed through or reflected off the tissue bed, and the
frequency of the emergent light is read by a sensor and
analyzed.
◦ The machine determines the oxygen saturation (Spo2) by
calculating the difference between levels of oxygenated
and deoxygenated hemoglobin based on subtle
differences in absorption of light.
 Contd.
◦ During oxygen administration the oxygen saturation
should be equal to or greater than 95%.
◦ A pulse oximeter reading of 90% to 94% must be
investigated because it indicates that the patient is
hypoxemic.
◦ Saturation less than 90% indicates a need for therapy.
◦ Saturation less than 85% for longer than 30 seconds is
a medical emergency.
◦ Regardless of the cause, patients with subnormal Pao2
or Spo2 readings may require supplemental oxygen
delivery, or ventilation through bagging or use of a
ventilator
Indicators of Ventilation
1. Respiratory Rate
2. Tidal Volume
3. Respiratory Character
4. Apnea Monitor
5. Capnograph (End Tidal CO2 Monitor)
6. Blood Gas Analysis
Respiratory Rate
◦ The RR is the number of breaths per minute (breaths/min). It is most often monitored by watching
the chest wall.
◦ it may also be monitored by observing movements of the reservoir bag
◦ RR may also be monitored mechanically with an apnea monitor or capnograph. The apnea
monitor generates an audible beep with each breath, and a capnograph displays a digital readout
of the RR in breaths per minute.
◦ Normally it must be in the range of 8-20 breaths per minute in case of Dogs and cats
◦ Tachypnea must be noted carefully as it denotes arousal or transition form surgical to lighter plane
of anesthesia.
◦ It must also be differentiated from Panting, which is usually open mouth and due to hypercapnia.
Tidal Volume
◦ It refers to the amount of air inhaled during a
breath.
◦ It usually falls by 25% under the effect of
preanesthetic as it relaxes the intercostal muscles.
◦ May cause atelectasis of the alveoli of the dependent
part
◦ It can be reversed by Bagging or Sighing the patient.
◦ It is measured using a Respirometer.
Respiratory Character
◦ It refers to the effort required to breathe, the length of inhalation and
exhalation and its regularity.
◦ Gasping may indicate insufficiency
◦ Inspiration lasts for 1-1.5 seconds and Expiration for 2 to 3 seconds.
◦ It is observed by chest wall movements and abnormalities ruled out by
auscultation
◦ Cats and Dogs do not have any respiratory sounds.
Apnea Monitor
◦ Warns if the patient has not taken a breath
◦ Placed between Endotracheal tube Connector and
Breathing Circuit
◦ Monitors the temperature of inhaled and exhaled
air
◦ Audible beep for normal breathing and rings
alarm bells if patient misses breath for a long
period of time.
Capnograph (End Tidal CO2 Monitor)
◦ A capnograph measures the amount of CO2 in the air that is
breathed in and out by the patient.
◦ Capnography is a noninvasive, continuous, and practical method of
monitoring CO2 levels in anesthetized patients without the need to
catheterize an artery, as is necessary with blood gas analysis.
◦ Although this monitoring device does not measure blood CO2
directly, expired CO2 closely mirrors arterial CO2 (Paco2).
Specifically, end-tidal CO2 (ETco2) is about 2 to 5 mmHg less than
Paco2.
◦ It consists of a sensor and a computerized monitor with a digital
readout.
◦ The sensor measures infrared light absorption, which is directly
proportional to the CO2 level.
◦ In a unanesthetized patient, an ETco2 of 35 to 45 mmHg is
considered normal. In contrast, when a patient is anesthetized, up to
55 mmHg is considered normal because the respiratory depression
produced by most anesthetics causes the body to retain CO2.
Blood Gas Analysis
◦ Blood gas analysis refers to the measurement of blood pH, and of
dissolved oxygen and carbon dioxide gas in arterial (Pao2 and Paco2) or
venous (Pvo2 and Pvco2) blood.
◦ It is therefore an indicator of both oxygenation and ventilation, as well as
acid–base status.
◦ Rarely used in small animals
Body Temperature
◦ Monitored every 15-20 minutes
◦ Important to know the status of Thermoregulation
◦ Anesthetics generally cause a general hypothermia and it is observed most
prominently in the first 20 minutes and can range of 3℃
◦ Body temperatures in the range of 32° C to 34° C (89.6° F to 93.2° F) prolong
anesthetic recovery and significantly decrease the dose of anesthetic agents
required. Temperatures below 32°C (89.6° F) cause dangerous CNS depression
and changes in heart function.
Reflexes and Other Indicators
Reflexes
◦ It is an unconscious response to the stimulus
◦ These generally are diminished as the anesthetic depth increases
SWALLOWING REFLEX:
◦ The swallowing reflex is a response to the presence of saliva or food in the pharynx.
◦ This reflex is monitored by watching for swallowing motions in the ventral neck region.
◦ The swallowing reflex is present in light Stage III anesthesia, is lost in surgical anesthesia, and
returns during recovery just before the patient regains consciousness.
◦ The return of the swallowing reflex during recovery is the main indicator used to determine when it
is safe to remove the endotracheal tube.
LARYNGEAL REFLEX:
◦ The laryngeal reflex is an immediate closure of the epiglottis and vocal cords when the larynx is
touched by any object.
◦ This reflex protects the animal from tracheal aspiration.
◦ The laryngeal reflex may be observed during intubation, is present if the animal is in a lighter plane
of anesthesia, and can make it difficult to pass the endotracheal tube.
◦ It is strong in cats, pigs, and small ruminants. It may lead to Laryngospasm which is a complication
of intubation.
PALPEBRAL REFLEX
◦ The palpebral reflex (blink reflex) is a blink in
response to a light tap on the medial or lateral
canthus of the eye.
◦ When eliciting this reflex, it is important to use
a “light touch,” because vigorous tapping may
artificially cause the eyelid to move, giving the
anesthetist a false-positive response.
◦ Some anesthetists prefer to test this reflex by
lightly stroking the hairs of the upper eyelid
◦ Significant in small animals for judgement of
depth as it must be lost in deep anesthesia at
stage III.
PEDAL REFLEX
◦ The pedal reflex is flexion or withdrawal of the limb in
response to vigorous squeezing and twisting or pinching
of a digit or pad.
◦ This reflex is useful only in small animal patients. The
pedal reflex varies, depending on the anesthetic depth,
from a very subtle contraction of muscles to a full
withdrawal of the limb.
◦ Because false-negative responses are common, accurate
assessment of this reflex requires a stimulus of a
surprisingly high intensity (a really hard squeeze and
twist), although obviously it must not be so forceful as to
injure the patient.
CORNEAL REFLEX
◦ The corneal reflex involves retraction of the eyeball within the orbit and/or a blink in response to
stimulation of the cornea.
◦ It is tested by touching the cornea with a sterile object (a drop of saline or artificial tear solution is
commonly used).
◦ As an alternative, the cornea can be stimulated with indirect digital pressure through the upper eyelid
(Figure 6-40).
◦ This reflex is most useful in large animals but is very difficult to elicit in small animals, except when the
patient is under very light anesthesia.
◦ Retraction of the eye is often subtle and best seen by positioning oneself so that the line of sight is near
the same horizontal plane as the cornea.
PUPLILARY LIGHT REFLEX
◦ The PLR is a constriction of the pupils in response to shining a bright light onto one of the retinas.
DAZZLE REFLEX
◦ The dazzle reflex is a blink in response to shining a bright light on the retinas. It has the same
significance as the PLR but is generally lost very early.
Other Indicators of Depth
◦ SPONTANEOUS MOVEMENT
◦ MUSCLE TONE
◦ EYE POSITION
◦ PUPIL SIZE
◦ NYSTAGMUS
◦ SALIAVRY AND LACRYMAL SECRETIONS
◦ HEART AND RESPIRATORY RATES
◦ RESPONSE TO SURGICAL STIMULATION
Pupil Size
◦ The size of the pupil also
varies with anesthetic depth;
pupils are dilated (mydriatic)
during stage II anesthesia,
normal or constricted (miotic)
during light Stage III
anesthesia, progressively
dilate as anesthetic depth
increases, and are widely
dilated during deep Stage III
anesthesia.
 Our goal is stay in the sweet spot of anesthetic depth that prevents
arousal during procedure and does not confer failure of vital systems,
particularly the Cardiovascular and Respiratory Systems.
Thank You