Monitoring and O2 Therapy

By
DR. Ahmed Elshafie

Lecturer of anesthesia
continuous clinical and
electronic observation of the
patient so that adverse
conditions can be detected
early and corrected before
doing any harm and prevent
an aesthetic- related
morbidity and mortality
*Monitoring system can

never reduce the importance
of clinical observations in
providing safe anaesthesia
using very simple measures
including: afinger on pulse,
an ear to listen to breath and
American Standards Of Basic
Intraoperative
Standard I: Monitoring:
The anaesthetist should be present in the
room throughout the period of anaesthesia.
Objectives: To monitor the patient and
provide anaesthesia care
Standard II:
During all anaesthetics the
patient’s:
1.Oxygenation
2.Ventilation
3.Circulation
4.Temprature should be
continually evaluated
Oxygenati
on:
Objectives:
to ensures adequate oxygen concentration
in the inspired gas (FIO2)
Methods:
1. FIO2 monitored by O2 analyzer with a low
O2 concentration limit alarm
2.Pulse oximeter (SaO2)
3.Assess patient’s colour
Ventilation:
Objective:
to ensure adequate ventilation of the patient
during all anaesthetics
Methods:
1. Clinical observation of chest
expantion ,reservoir breathing bag and
auscultation of breath sounds.
2. End tidal CO2 monitoring.
3. Tidal and minute volumes measurements.
4. Ventilator disconnection alarm.
Circulation:
Objectives:
To ensure the adequacy of the
patient’s circulatory function during
all anaesthetics
Methods:
1. Continuous ECG monitoring.
2. Arterial blood pressure and heart
rate at least every 5 min.
3. Palpation of the pulse and
auscultation of heart sounds.
Body temperature:
Objectives: To maintain body temperature

during all
anaesthetics.
Methods: Patient’s temperature should be

measured when changes in body
temperature are intended or suspected.
:Important points
a) All be equipments must be checked before use and all

alarm limits should set.
b) Both the patient and the an aesthetic machine must be

monitored.
c) Monitoring must begin before induction and continue

until the patient has recovered from the effects of
anaesthesia.
d) The same standards of monitoring should be applied

during all anaesthetics (general or regional).
e) Monitoring are not likely to be of value unless the

anaesthetist can recognize problems and act
accordingly.
f) In major surgery, more additional monitoring may be

needed e.g. invasive blood pressure, cardiac output, ……
etc.
Oxygen therap
When treating acute hypoxemia; the
primary goal is to alleviate tissue
hypoxia in order to preserve vital
organ functions
when giving oxygen; one must decide

on the mode of administration; the
.dosage and the end point
:physiological backgrounds
In the body; oxygen is essential for tissue

metabolism. The site of O2 is the cell
mitochondria the delivery of oxygen to the
cell mitochondria occurring in 4 phases:
1- Inspired O2is transported to the alveoli by the
process of breathing.
2- ThenO2 in the alveoli transported to blood by
the process of gas exchange.
3- Oxygenated blood is then transported into
tissues by the effect of blood flow (co).
4- Finally; diffusion of oxygen occurs between
blood stream tissue capillaries and cell
mitochondria where aerobic metabolism occurs.
Failure of any step of O2 transport
results in hypoxia;
which defined as an inadequate tissue

oxygenation due to either inadequate
.blood flow or low arterial O2 content
- :O2 is carried out in the blood by two ways
a) O2 dissolve into the blood; the amount

that dissolves depends on Pao2 therefore;
arterial blood at pao2 of 100 mmHg
contain 0.3 ml O2/dl
b) O2 combines chemically with Hb: 1g Hb

combines with 1.34 ml of O2 most O2 in
blood is carried in combination with Hb.
:Goal of O2 therapy
Hypoxemia is considered to be present when

paO2 is <60 mmHg (i.e. saO2 <90%)
therefore the goal of therapy in critically ill

patients is to increase saO2 to >90% (i.e.
paO2 > 60 mm Hg) values greater than
this do not significantly raise the O2
content because of the shape of the
oxyhaemoglobin dissociation curve.
furthermore, at this level of oxygenation

the symptoms, sings and morbidity of
hypoxemia are usually eliminated.
:Indications of O2 therapy
the most common indication is prevention-1

&correction of arterial hypoxaemia
:Causes of hypoxemia are

a)Low inspired O2(high attitude)
b)hypoventulation(respiratory depression by drug)
c) ventilation/perfusion mismatch(post operative)
d)Intrapulmonary shunt(pulmonary oedema,ARDS)
e)Impaired diffusion
d)Circulation problems(stagnant hypoxemia)
g)Toxic hypoxemia(CO&cyanide poisoning)
h)Anaemic hypoxemia(sever anaemia)
O2 is provided before procedures:tracheal-3
suction,bronchoscope as they cause arterial
desaturation
prevention &treatment of diffusion hypoxia-4

Sources of O2 in hospital
There are two sources:

*O2 is made available in high pressure
cylinders, via pipeline systems, from oxygen
concentrators (extracted from air) as well as in
liquid form.
*The amount of O2 (L/min) is controlled during O2

therapy by the use of flow meter and then the
gas is conducted to the humidifier before it
finally reached the patients.
: Methods of O2 therapy
A) low flow systems:

1- They provide a reservoir of O2 for patients to
inhale.
2- FIO2 is variable (not constant).
3-rebrething of expired air is possible (not all methods).
4-they are popular methods because of their simplicity;

patient comfort and cheap.
5-they include:
*nasal cannula;
*nasal mask;
*simple face mask;
*masks with reservoir bag
and others (e.g. face tent, O2 tent).
Nasal cannula:
* It consists of two pronges placed 1 cm into the nares.
* It should be changed at least daily.
* It delivers a constant flow of O2 to pharynx; which act as O2

reservoir.
*As O2 flow rate increased from 1 to 6 L /min; the FIO2

increased from 0.24 to 0.46.
*useful in long term oxygen therapy.
*effective; easy to use; well tolerated and allow speech; well

tolerated and allow speech, eating and drinking.
* pediatric sized annuals are available.
*at high flow of O2 (>5 L/min) it causes uncomfortable

dryness and encrustation of secretions.
: Nasal mask
*designed to be in a way to surround the external nose.
* The primary advantage is patient comfort as oxygen is not

"jetted" into nasal cavities with nasal cannula.
* Oxygen supply as with nasal cannula.

:Simple face mask
*most common method of O2 therapy.
* Disposable, light-weighted plastic device that nose and

mouth and contains no valves or reservoirs.
*the face seal is never tight; therefore patient receives a

mixture of pure oxygen and secondarily entrained room air.
*they provide an FI02 of 0.35 to 0.60 when o2 flow is 5-10

L/min.
*Drinking/eating is difficult
and long term use is uncomfortable.
:Masks with reservoir bags
*disposable, light-weighted transported plastic with reservoir

bag from which the patient breathes.
* The reservoir bag should be kept inflated, so that the patient

will inhale only the gas contained in the bag.
*thus, the FIO2 can be to some extent controlled provided

proper application of the mask.
* Because the mask should be fit on face,

it is not possible to feeds patient
by nasal or oral route.
There are two types of these masks:
:partial rebreathing masks-1
.provide delivery of a relatively high FIO2 up to 0.7-0.8 *
Part of expired VT refilling the bag, but most of expired gas *

and co2 are eliminated from the mask through side holes by
using high flow of O2 (5-15L/min)
2-Non-rebreathing masks:
*have a one-way valve that

prevents any expired gas from
returning to the reservoir bag (i.e.
non breathing).
*thus, this permits inhalation of

fIO2 (0.8-0.95)
:B) High flow systems (air entrainment ventimasks)
1- Oxygen is directed by small-bore tubing to a mixing jet, the

final oxygen concentration depends on the ratio of air drawn in
through entrainment ports.
2- They provide a constant FIO2.
3- Thus, they are more suitable for controlled O2 therapy in

COPD.
4- rebreathing dose not occur (due to high flow of gas).
5- Thus, no valves or reservoirs are needed.
6-a major drawback, inability to deliver FIO2.> 0.6.
7- These masks deliverFIO2 from 0.24-0.6.
8- FIO2 can be increased if the entrainment ports are

obstructed or occluded.
:C) Hyperbaric o2 therapy (HBO)
HBO is inhalation of O2 at increased pressure (hyperbaric) and

.it is administered by using hyperbaric chamber
The principle goal of HBO is to increase the concentration of

dissolved O2 in the blood and tissues for the treatment of
.diseases
In this case, paO2 in excess of 1500 mmHg may be produced

.by the inhalation of 100% O2 at 2-3 atmospheric pressure
HBO is mainly used for decompression sickness, CO poisoning,
gas gangrene, gas embolism, problem wounds and crushed
airway.
: Hazards of O2 therapy
1- Ventilatory depression:
*it occurs in COPD patients with hypoxic drive.
* Elimination of the hypoxic drive by administration of high

Flo2 may lead to serve hypoventilation and apnea.
* These patients should receive controlled o2 therapy better

by using ventimasks (low Flo2).
2- Absorption atelectaisis:
*Alveoli tend to remain patent because of the presence of

nitrogen (nitrogen splinting) however high O2 concentration is
rapidly denitrogenate alveoli. Thus become unstable and
collapse
3-Pulmonary O2 toxicity:
*Although O2 is for aerobic metabolism , inappropriate O2

metabolism can be toxic .
* There is evidence that inhalation of high concentrations of

O2 (> 60%)
For prolonged periods (1-2 days) can produce deleterious
effects on the lungs (acute lung injury)
*To avoid pulmonary O2 toxicity: -

- only give O2 when indicated .
- Reduce FIO2 as low as possible ( 0.5 – 0.6 ) .
4 – Retinopathy of prematurity :
*Is another form of O2 toxicity that occurs in neonates who are

exposed , to high 02 concentrations .
5 – Fire hazards
*Oxygen vigorously supports combustion .

.N.B
- What is meant by FIO2 ?
FIO2 denotes the fraction of O2 in the inspired gas

The FIO2 and in the O2 cylinders is 1.0 ( I . e . 100% ) .
-What is the normal PaO2 if FIO2 is 0.21

( air ) and 1.0 ?
PaO2 on breathing room air is about 97 mmHg in young

adult and if
FIO2 is 1.0 normal PaO2 should be 500 – 600 mmHg .
Thank you

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By

DR. Ahmed Elshafie

*Monitoring system can

Objectives: To maintain body temperature

Methods: Patient’s temperature should be

a) All be equipments must be checked before use and all

b) Both the patient and the an aesthetic machine must be

c) Monitoring must begin before induction and continue

d) The same standards of monitoring should be applied

e) Monitoring are not likely to be of value unless the

f) In major surgery, more additional monitoring may be

when giving oxygen; one must decide

In the body; oxygen is essential for tissue

which defined as an inadequate tissue

a) O2 dissolve into the blood; the amount

b) O2 combines chemically with Hb: 1g Hb

Hypoxemia is considered to be present when

therefore the goal of therapy in critically ill

furthermore, at this level of oxygenation

the most common indication is prevention-1

:Causes of hypoxemia are

prevention &treatment of diffusion hypoxia-4

There are two sources:

*The amount of O2 (L/min) is controlled during O2

A) low flow systems:

2- FIO2 is variable (not constant).

3-rebrething of expired air is possible (not all methods).

4-they are popular methods because of their simplicity;

* It should be changed at least daily.

* It delivers a constant flow of O2 to pharynx; which act as O2

*As O2 flow rate increased from 1 to 6 L /min; the FIO2

*effective; easy to use; well tolerated and allow speech; well

* pediatric sized annuals are available.

*at high flow of O2 (>5 L/min) it causes uncomfortable

*designed to be in a way to surround the external nose.

* The primary advantage is patient comfort as oxygen is not

* Oxygen supply as with nasal cannula.

*most common method of O2 therapy.

* Disposable, light-weighted plastic device that nose and

*the face seal is never tight; therefore patient receives a

*they provide an FI02 of 0.35 to 0.60 when o2 flow is 5-10

*disposable, light-weighted transported plastic with reservoir

* The reservoir bag should be kept inflated, so that the patient

*thus, the FIO2 can be to some extent controlled provided

* Because the mask should be fit on face,

:partial rebreathing masks-1

.provide delivery of a relatively high FIO2 up to 0.7-0.8 *

Part of expired VT refilling the bag, but most of expired gas *

*have a one-way valve that

*thus, this permits inhalation of

1- Oxygen is directed by small-bore tubing to a mixing jet, the

2- They provide a constant FIO2.

3- Thus, they are more suitable for controlled O2 therapy in

5- Thus, no valves or reservoirs are needed.

6-a major drawback, inability to deliver FIO2.> 0.6.

7- These masks deliverFIO2 from 0.24-0.6.

8- FIO2 can be increased if the entrainment ports are

HBO is inhalation of O2 at increased pressure (hyperbaric) and

The principle goal of HBO is to increase the concentration of

In this case, paO2 in excess of 1500 mmHg may be produced