Beginner’s

Guide
Datex-Ohmeda Academy
Foreword

Dear Reader,

This Beginner’s Guide has been prepared for you who have recently joined the sales,
marketing, technical or administrative team of your country. As you may not be familiar with
Datex-Ohmeda’s business, we would like to provide you with the basics for understanding;
- how the vital organs normally function,
- the anesthesia and critical care environments and processes, and
- the key elements in monitoring the safety of the patient.

The material has been designed to be used either for self-study or in the classroom at the
Datex-Ohmeda Academy, or in your company’s local training. There will be a test based on
this material before entry to the next series of Datex-Ohmeda training courses.

We hope that this introduction helps you to start a continuous learning process to understand
the work, the working environment and the needs of your customers. This understanding is
essential to achieving a fruitful and productive interaction with professionals in the field.

Welcome to the Datex-Ohmeda TEAM and to the challenging and rewarding world of anesthesia
and critical care!

Yours truly,

Kirsi Nuotto
Global Training Manager
Datex-Ohmeda Division
Instrumentarium Corporation

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Contents
FOREWORD

LEARNING OBJECTIVES ................................................................................................................ 1

1 BREATHING IS THE FIRST STEP .............................................................................................. 2

2 RESPIRATION ................................................................................................................................ 4
2.1 The Respiratory Organs .................................................................................................... 4
2.2 Mechanics of Respiration ................................................................................................. 6
2.3 Lung Volumes and Capacities ......................................................................................... 7
2.4 Phases of Respiration ........................................................................................................ 8
2.5 Problems with Ventilation and Pulmonary Perfusion ............................................. 10
2.6 Humidification ................................................................................................................. 11

3 CIRCULATION ............................................................................................................................ 13
3.1 Elements of Circulation .................................................................................................. 14
3.2 Anatomy of the Heart ..................................................................................................... 15
3.3 The Heart’s Electrical Activity ...................................................................................... 16
3.4 Cardiac Cycle ................................................................................................................... 18
3.5 Factors Affecting Cardiac Output ................................................................................ 18

4 OXYGENATION .......................................................................................................................... 20

5 METABOLISM ............................................................................................................................. 21

6 NEUROPHYSIOLOGY ................................................................................................................ 26
6.1 The Nervous System ....................................................................................................... 26
6.2 Brain Anatomy ................................................................................................................. 27
6.3 Factors Affecting Nervous Function ........................................................................... 28

7 THE ANESTHESIA PROCESS .................................................................................................. 30

7.1 General Overview ............................................................................................................. 31
7.2 Historical Review ............................................................................................................ 32
7.3 Phases of Anesthesia ...................................................................................................... 32
7.4 Drugs During Anesthesia ............................................................................................... 38
7.5 Equipment for Anesthesia Delivery ............................................................................. 40

8 THE CRITICAL CARE PROCESS ............................................................................................ 44

8.1 Historical Review ............................................................................................................ 44
8.2 Introduction to Critical Care ......................................................................................... 44
8.3 Critical Care Facilities .................................................................................................... 46
8.4 Phases of Critical Care ................................................................................................... 48
8.5 Monitoring and Equipment Used During Critical Care .......................................... 50
8.6 Ventilation in Critical Care ........................................................................................... 53

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
9 PATIENT MONITORING ............................................................................................................ 57
9.1 Ventilation: Patient Spirometry .................................................................................... 58
9.2 Patient Oxygen ................................................................................................................ 64
9.3 Inhalational Anesthetic Agents and N2O ................................................................... 66
9.4 Electrocardiogram .......................................................................................................... 69
9.5 Cardiac Output ................................................................................................................ 72
9.6 Blood Pressures ................................................................................................................ 74
9.7 Tissue Oxygenation - SpO2 ................................................................................................................................................................ 79
9.8 Gas Exchange ................................................................................................................... 82
9.9 Mixed Venous Oxygen Saturation ............................................................................... 84
9.10 Carbon Dioxide .............................................................................................................. 85
9.11 Temperature ................................................................................................................... 87
9.12 Neuromuscular Transmission .................................................................................... 88
9.13 Electroencephalography .............................................................................................. 90
9.14 Gastric Tonometry ........................................................................................................ 93

ANSWERS TO TASKS ................................................................................................................... 95

APPENDIX ..................................................................................................................................... 100

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
LEARNING OBJECTIVES
This publication will help the reader understand:

1. The basic physiological functions and the purpose of ventilation, circulation and
oxygenation; the clinical parameters related to them and their normal values.

2. Anesthesia as a process and how intervening with the patient’s normal functions
could harm the patient’s well-being.

3. The critical care environment and processes and how they differ compared to
anesthesia.

4. The importance of careful planning of care processes and keeping watch

over the patient.

5. Different elements of the processes including patient care, ventilation

management, monitoring and information management.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 1
 1 BREATHING IS THE FIRST STEP

5. oxygenation of cells
metabolism by cells

1. inspiration 2. diffusion 3. circulation

O2

6. expiration
CO2 O2

4. perfusion

3. circulation

The human body needs oxygen (O2) to By analogy oxygen is brought in by the lungs
survive and every breath of air brings a (1), from where some of it is taken into the
sufficient amount of it into our lungs. bloodstream (2), is carried by the circulating
Breathing normally does not require a blood to the vital organs and tissues (3), and
conscious effort but is automatically control- is released to the organs and tissues (4) to
led by the brain even during critical ill- keep them oxygenated1. Organ and tissue
nesses. Being out of breath after hard cells use the oxygen as fuel to produce
exercise or suffering from a severe cold energy (5). A product of this metabolic
brings this normally subconscious function process is carbon dioxide (CO2) which is
to the conscious surface. eliminated via the same transport system
that brought in the oxygen (6).
The lungs can be compared to the conveyor
belt of a dairy loading station. Milk bottles Breathing in is called inspiration and
are brought out of the dairy to be picked up breathing out is called expiration. The
by milkmen and transported in milk delivery movement of gas into and out of the lungs is
trucks to various addresses. The mother called ventilation.
1
oxygenation = gives the milk to her thirsty children and
saturation with oxygen
takes the empty bottles to the door. The Obviously both ventilation and circulation
2
metabolism = milkman then collects the empty bottles and need to be in balance to ensure adequate
all chemical and energy
transformations that occur loads them onto the truck, drives back to the oxygenation of and metabolism2 by the
in the body
dairy and places the empty bottles on the organs and tissues.
metabolic =
adjective for metabolism return side of the conveyor belt.

2 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 1 Breathing is the first step
Q1. What organ regulates breathing and how?

Q2. Describe the steps through which oxygen passes to produce energy.

Q3. What does ventilation mean?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 3
 2 RESPIRATION
Respiration as a general term refers to the and carbon dioxide between the lungs and
act of breathing. It originates from Latin: the atmosphere (ventilation), the lungs and
‘‘re’’ means back (and forth) and ‘‘sprirare’’ the blood (diffusion), the blood and the cells
means to breathe. In medical terminology, (perfusion and diffusion) and within the
respiration includes all exchange of oxygen cells (metabolic gas exchange).

2.1 The Respiratory Organs

The Conductive Airways
Nose: purifies, warms up and humidifies inhaled
gases

Pharynx (Throat): common passageway for air

and food. Swallowing is caused by nerve reflexes
that close the epiglottis, leading food into the
esophagus. An open epiglottis allows air to enter
the lungs. The epiglottis hangs over the larynx
which protects the airway and contains the vocal
cords that enable speech.

Trachea (Windpipe): air enters the lungs via the

trachea that branches into two main bronchi3.
The right principle bronchus continues almost
straight down the course of the trachea while the
left one turns more sideways. The bronchi further
branch into smaller and smaller bronchioles. The
trachea, the bronchi and the bronchioles together
form the “tracheobronchial tree”.

The above respiratory organs form the

conductive airways. There is no gas
exchange in the conductive airways. In
adults their volume in milliliters approxi-
mately equals the bodyweight in kilograms
multiplied by 2.2. Thus for a bodyweight
of 70 kg the conductive airways take up
150 ml of the total volume of 500 ml for
one breath.

3
singular: bronchus,
plural: bronchi, adj:
bronchial

4 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
The Alveoli
The terminal bronchioles open into alveolar smallest blood vessels, the capillaries, which
sacs, which contain several alveoli4, the bring blood into contact with the alveolar
smallest units in the lungs. The diameter of walls. Oxygen diffuses through the wall into
these tiny cavities is only 0.1 mm but the the blood and carbon dioxide diffuses into
more than 300 million of them take up a the alveoli from the blood. During inspira-
volume of a few liters and, spread out, would tion the alveoli distend with the air flowing
cover a surface area of 70-100 m2. The into them and at expiration the air is driven
alveoli are surrounded by a network of the out of the lungs and the alveoli deflate.

Inspiration Diffusion of oxygen from

O2 alveolus to blood
Capillary
AIRWAY

Expiration Alveolus
CO2
O2
Diffusion of carbon Alveolar sac
dioxide from blood
to alveolus

The Lungs
The lungs consist of the tracheobronchial
tree and the alveoli. The right lung has three
lobes and the left two lobes, reserving a
space for the heart.

The space for the lungs in the body is called the

thoracic cavity. Each lung and the inner walls of
the thoracic cavity are covered by two thin layers
of tissue, the pleurae5. The space between these
two layers is called the pleural cavity and con-
tains a small quantity of fluid that prevents
friction against the rib cage during the movement
of the lungs at inspiration and expiration. Under
normal conditions the intrapleural6 pressure is
negative.

4
singular: alveolus, plural:
alveoli, adj: alveolar

5
singular: pleura, plural:
pleurae

6
intrapleural =
between the two pleurae

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 5
 2.2 Mechanics of Respiration
Inspiration results from muscular contrac- draws air into the lungs. The return of the
tions that increase the volume of the chest, thoracic cavity to its original volume pushes
creating a subatmospheric7 pressure that air out of the lungs at expiration.

Diaphragm

Inspiration: diaphragm moves towards the Expiration: diaphragm moves away from the
abdomen abdomen

The main inspiratory muscle is the Inspiration - whether in spontaneous or me-

diaphragm . It separates the thoracic chanical ventilation - is an active process which
cavity from the abdominal cavity and requires energy. The energy for spontaneous
moves down during inspiration. When breathing is produced by metabolism. For
the diaphragm relaxes it moves back mechanical ventilation the ventilator supplies
up during expiration. The other inspira- the energy.
tory muscles are the external intercostal
muscles which run obliquely forward The normal respiration rate (RR) for an adult
and downward from rib to rib. at rest is 12-15 breaths/minute and for a
newborn baby 30-40 breaths/minute.

500
250 volume
ml
0
10

Intrapulmonary 0
pressure cm H20
Intrapleural
pressure
-10
Inspiration Expiration

7
subatmospheric =
lower than atmospheric
intrapulmonary =
within the lungs

6 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
2.3 Lung Volumes and Capacities
Typical adult
values
TLC 5000 ml
TLC

IRV

VC IC VC 3500 ml
TV FRC 3000 ml
FEV1 70-85 %
IRV 2000 ml
ERV
FRC

ERV 1000 ml
RV 1800 ml
RV RV
TV 500 ml

The measurement of various lung volumes Inspiratory reserve volume (IRV) is the
and capacities gives information on its maximum volume of air that can be inspired
ventilatory capability. Total lung capacity in addition to a normal inspiration. Expira-
(TLC) is the total volume of air in the lungs tory reserve volume (ERV) is the maximum
at maximal inspiration. Vital capacity (VC) is volume of air that can be expired after a
the highest volume of air that can be expired normal expiration. Residual volume (RV) is
after a maximal inspiratory effort. VC is the volume remaining in the lungs after a
frequently measured as a clinical estimation maximal expiration. RV cannot be measured
of pulmonary function. Functional residual directly.
capacity (FRC) is the volume remaining in
the lungs after a normal expiration. Inspira- Tidal volume (TV) is the amount of air that
tory capacity (IC) is the volume of maximal moves into and out of the lungs during each
inspiration after a normal expiration. breath. Normally only about two thirds of the
tidal volume reach the alveoli, resulting in an
The fraction of the vital capacity expired alveolar ventilation of 350 ml. Tidal volume
during the first second (FEV1) of expiration multiplied by respiration rate is called the
gives information on the ease of expiration. minute volume (MV): TV x RR = MV.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 7
2.4 Phases of Respiration
Ventilation
Ventilation is the movement of gases into through the interface separating the alveoli
and out of the lungs. The distribution of gas from the blood. O2 diffuses from the alveoli
within the lungs depends on the posture and to the blood and CO2 from the blood to the
on the elasticity of the lungs. Alveolar alveoli.
ventilation is affected by the dead space and
by the depth and rate of respiration. The diffusion boundary is a semi-permeable
membrane, called the alveolar capillary
Dead Space membrane. Factors that affect the diffusion
process include the thickness and integrity
The part of tidal volume which remains in
of the membrane, pressure differences
the conductive airways is called the ana-
between alveolar air and the capillary blood,
tomical dead [Link] volume of alveoli
and the effective area of diffusion.
which are ventilated but do not allow
diffusion of gases is called alveolar dead
space. The Effect of Respiration Rate
and Tidal Volume on Alveolar
Diffusion Ventilation
Diffusion is the spontaneous movement of Because of the dead space, rapid and shal-
molecules from a region of higher concentra- low breathing produces much less alveolar
tion (pressure) to a region of lower concen- ventilation than slow and deep breathing at
tration (pressure). The oxygen (O2) and the same minute volume (see the table
carbon dioxide (CO2) molecules each diffuse below).

Respiration Rate/min 30 12
Tidal Volume, ml 200 500
Dead Space, ml 150 150
Minute Volume, ml 6000 6000
Alveolar Ventilation, ml 30 x (200-150) = 1500 12 x (500 - 150) = 4200

At sea level, air has a mean barometric pressure

of 760 mmHg. Dry air contains 21 % oxygen and
Capillary Bed 78 % nitrogen. The partial pressure of O2 (PO2) is
thus 0.21 x 760 = 160 mmHg. The water vapour in
the air in most climates reduces these percent-
ages and therefore also the partial pressures
slightly. Air equilibrated with water is saturated
with water vapour, and inspired air is saturated
by the time it reaches the lungs. Alveolar air
Alveolus partial pressures are PO2 = 100 mmHg and
PCO2= 40 mmHg.

Alveolar sac

8 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Partial Pressures of Oxygen and Carbon Dioxide

160
140 O2
120
100
mmHg

80
60
40 C O2

20
0
Air Alveoli Artery (O2)/Vein (CO2) Tissue

Diffusion always proceeds from a higher concentration (and pressure) area to a lower one.

Perfusion
Perfusion is blood flow through the capil- Lying on the back, the back areas of the lung
lary. Perfusion of the pulmonary capillaries contain more blood. Thus the distribution of
is a prerequisite for the diffusion of oxygen lung perfusion varies and some capillaries
from the alveoli and of carbon dioxide to the are normally closed. Circulation then carries
alveoli. It is influenced to a great extent by the blood to the tissues and organs. Organ
gravity: in the upright position more blood is and tissue perfusion is a prerequisite for the
present at the basal part of the lung than in delivery of oxygen from the blood and the
the top area. uptake of carbon dioxide by the blood.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 9
2.5 Problems with Ventilation and
Pulmonary Perfusion
normal ventilation
and perfusion
inspiration expiration

tracheo-
bronchial
tree

perfusion reduced

diffusion barrier

blood from
pulmonary
artery

reduced
blood from ventilation
pulmonary
artery

Dead Space Ventilation Shunt

The dead space ventilation of a well venti- Some parts of the lungs may be well
lated but non-perfused part of the lungs perfused but poorly ventilated. This shunt
results in the dilution of the CO2-rich alveo- perfusion decreases arterial blood oxygen
lar gas from the rest of the lungs with CO2- content as the poorly or non-oxygenated
free gas from the non-perfused area. This blood mixes with blood from ventilated
lowers the end-expiratory concentration of parts of lung.
CO2 (end-tidal CO2, EtCO2).

10 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
 too efficient ventilation

➤
too efficient removal

decreased production

➤
➤ C O2 ➤ ALKALOSIS

➤
Acid-base Imbalance
The CO2 that is produced by cellular metabo- ventilation (hypoventilation). The opposite
lism diffuses from the cells to the capillary of acidosis is called alkalosis, which may
blood. It combines with water (H2O) to form be caused by too efficient ventilation
carbonic acid which, in turn, maintains a (hyperventilation).
delicate balance between dissolved CO2, the
bicarbonate anion (HCO3- ) and the hydrogen
ion (H+). The H+ ion concentration in blood, Regulation of Breathing
expressed in pH units which equal -log [H+], is
The hydrogen ions (H+), produced by the
strictly regulated.
reaction of CO2 with water, stimulate the
CO2+H2O <-> H2CO3 <-> H+ + HCO3- .
respiratory center which is located in the
The normal pH in blood is 7.4 +- 0.05
medulla (brain stem). Tidal volume and
breathing frequency increase to remove
If the CO2 increases, the H+ ion concentra-
excess CO2 from the body. Other receptors
tion rises (the pH falls) and the blood be-
which respond to low O2 cause an increase
comes acidic. This condition, known as
in tidal volume.
acidosis, can be caused by inadequate

2.6 Humidification
During normal breathing, the upper respira- which the inspired gases may also be very
tory tract acts as a natural heat and mois- dry. For this reason an artificial way of
ture exchanger, adding heat and moisture reducing heat and moisture loss is needed.
to the air during inhalation and recovering Two methods are used: heated humidifiers,
heat and moisture during exhalation. For which saturate inspired gas with heat and
this reason heat and moisture losses be- moisture; and the heat and moisture ex-
tween the lowest part of the respiratory changer (HME). The HME works like the
tract and the upper respiratory tract are upper respiratory tract and a good one will
quite small, the moisture loss normally keep the moisture loss at its normal value of
being 7 mg/l. 7 mg/l. It is sometimes referred to as the
"Swedish Nose" and is placed between the
When a patient is intubated, however, this endotracheal tube and the breathing tubes.
mechanism is less efficient, in addition to

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 11
Tasks 2 Respiration
Q1. What are the elements of the conductive airways?

Q2. What is the role of the epiglottis?

Q3. Name the inspiratory muscles.

Q4. What is diffusion?

Q5. What is perfusion ?

Q6. What are the two phases of respiration that must precede oxygen entering the blood?

Q7. What does “ anatomical dead space” mean?

Q8. How much of the total lung capacity does the tidal volume take up?

Q9. How much of the tidal volume does alveolar ventilation take up?

Q10. How much is the moisture loss during normal breathing?

12 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
3 CIRCULATION

The circulatory system serves as a transport • Cells (45 %): red blood cells for transport-
system for the body. Its primary function is ing O2, white blood cells for defence
to supply O2 to the tissues, return CO2 to the against infection, platelets8 or
lungs and other products of metabolism to thrombocytes9 for blood coagulation.
the liver and kidneys. It also has a role in the
regulation of body temperature and in the Red blood cells contain a special substance
distribution of hormones and other mol- called hemoglobin, which captures the
ecules that regulate cell function. oxygen molecules diffusing into the pulmo-
nary capillaries and becomes oxygenated
The carrier of these substances is the blood, (HbO2). When blood reaches the tissue or
which is pumped to all tissues in the body organ that needs the oxygen, the oxygenated
through a closed system of blood vessels. hemoglobin releases the oxygen and be-
Blood is composed of the following: comes deoxygenated (Hb). The ability of
hemoglobin to capture and release O2 is
• Plasma (55 %): water, proteins, nutrients, affected by pH and temperature among
hormones, sodium, chloride and waste other factors.
products

8
platelet =
found in the blood of all
mammals and chiefly
known for its role in blood
coagulation

9
thrombocytes =
platelets

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 13
3.1 Elements of Circulation
The circulatory system consists of two
complete circuits which are arranged in
series. The systemic circulation transports
the oxygenated blood pumped from the left pulmonary
side of the heart to the rest of the organs and circulation
tissues and back to the heart. The pulmo-
nary circulation receives deoxygenated
venous blood pumped from the right side of systemic
circulation
the heart, transports it to the lungs to be
oxygenated and returns it to the left side of
coronary
the heart. The third component of the circulation
circulatory system is coronary circulation
which delivers blood to the heart muscle.

capillary

venule
artery

vein

sphincter
arteriole

Circulation is controlled by various regula- capillaries where gas exchange takes place.
tory systems which function to maintain The arterioles are equipped with sphincters,
adequate capillary blood flow in all organs, little muscular rings that can constrict the
especially in the heart and brain. blood’s flow into the capillaries. The other
end of a capillary opens into a venule.
The blood vessels that leave the heart are Venules connect into veins which return the
called arteries. These branch into smaller blood to the heart.
arteries, called arterioles, which end in

14 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
3.2 Anatomy of the Heart
aorta
superior
vena cava pulmonary artery

pulmonary
valve
LA
aortic valve
RA
tricuspid
valve
LV
RV
mitral valve

inferior
vena cava

The heart functions as a two-sided pump 4) Left ventricle (LV): the blood from the left
(left and right). It is a four-chambered atrium enters the left ventricle through the
structure which consists of two atria (singu- mitral valve and is then pumped into sys-
lar: atrium; plural: atria) and two ventricles. temic circulation through the aortic valve
The atria lie above the ventricles and are and the aorta.
thin-walled reservoirs that supply their
respective ventricles with blood. The ventri- Malfunction of one or more of the valves
cles are thick-walled chambers. The right will lead to decreased pump function of the
chamber pumps the blood to the pulmonary heart.
arteries and the left chamber via the aorta to
the systemic arteries. The thoracic aorta divides into three parts:
the ascending part, the arch (giving
1) Right atrium (RA): the blood returning to branches to the upper extremities and
the heart from systemic circulation enters brain), and the descending part.
the right atrium through two large veins,
the superior vena cava and the inferior The heart is composed almost entirely of a
vena cava. specialized muscle called the myocardium.
The entire heart is covered by a fibrous non-
2) Right ventricle (RV): the blood from the elastic sac, the pericardium, which protects
right atrium enters the right ventricle the heart.
through the tricuspid valve. The blood is
then pumped via the pulmonary valve to
the pulmonary artery and to the lungs.

3) Left atrium (LA): acts as a reservoir for

oxygenated blood returning from the lungs
through the pulmonary veins.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 15
3.3 The Heart’s Electrical Activity
The heart muscle (the myocardium) consists The cardiac cycle begins with the creation of
of muscle cells and specialized conducting an electrical impulse in the SA node, located
tissue. The electrical activity of the heart in the right atrium. The rate is adjusted
coordinates the mechanical function of the according to the needs of the body.
cardiac cycle.
The impulse advances to the AV node and
Electrical Activation of the Heart through the bundle of His into the ventricles
via the bundle branches and Purkinje
The conduction system of the heart is
fibers. This changes the charge distribution
composed of the Sino-Atrial (SA) node
of the muscle cell membranes and results
(normal pacemaker), the compact atrioven-
in a measurable electrical signal, the
tricular (AV) node, and the His-Purkinje
electrocardiogram (ECG).
system.

SA node LA
Left Bundle Branch
AV node RA

Bundle of His RV LV

Purkinje fibers
Right Bundle Branch

Cellular Electrophysiology
The resting myocardial cells are polarized. After depolarization, the repolarization
The outside of the cell membrane is posi- process begins restoring the cell membrane
tively charged while the inside is negatively to its resting state again. During
charged. This negative state is maintained by repolarization the cell cannot be activated
active pumping of positive ions out of the again.
cell.
The cells of the conducting system in the
Electrical stimulus changes the intracellular heart have the ability to slowly depolarize
charge from negative to positive. This is themselves. When they reach a threshold
called depolarization. It stimulates the cells potential, they produce a propagated action
nearby and the depolarization is spread potential.
through the myocardium, leading to contrac-
tion of the heart muscle.

Resting cell Electric impulse Return to rest

= polarized = depolarization = repolarization

16 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Ischemia of the Heart Arrhythmias
Myocardial ischemia means inadequate Arrhythmia is an abnormal cardiac rhythm.
supply of oxygen to the heart muscle. The It usually occurs when the normal rhythm is
cause of myocardial ischemia is stenosis10 interrupted by stimuli created outside the
or spasm11 of a coronary artery, which SA node or when conduction is abnormal.
prevents blood flow. If the condition is The mechanical contraction of the heart
severe or prolonged, the area of ischemic muscle may then be affected.
tissue becomes injured (infarct), cell func-
tion ceases and irreversible cell death The main serious arrhythmias are ventricu-
follows. This may produce life-threatening lar tachycardia (rapid beats originating in
ventricular arrhythmia. Injured tissue is the ventricle (s)), ventricular fibrillation
unable to contract. The coronary arteries (chaotic activity not leading to mechanical
and their main divisions are illustrated here. contraction) and asystole (lack of all electri-
cal activity).
Depending on which coronary artery is
obstructed, different parts of the heart suffer
from the decreased blood flow and
ischemia.

3
4
2

1. Left Common Coronary Artery

2. Left Anterior Descending Artery
3. Circumflex Artery
4. Right Coronary Artery

10
stenosis =
a narrowing or constriction
of the diameter of a blood
vessel.

11
spasm =
an involuntary and
abnormal contraction of
muscle or a hollow organ,
e.g. an artery.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 17
3.4 Cardiac Cycle
Every contraction of the heart muscle The amount of blood pumped during one
delivers a certain volume of blood into minute is called the cardiac output (C.O.). It is
circulation. Between contractions the heart determined by the heart rate (HR) and the
muscle rests, becomes oxygenated through stroke volume (SV). Both sides of the heart
coronary circulation and fills up with more pump approximately the same amount of
blood. The period from the end of one heart blood to the arteries, typically SV = 70-100 ml
contraction to the end of the next is called for an adult. The heart beats at a rate of 60-80
the cardiac cycle. It consists of two phases: beats /minute. Normal adult cardiac output at
diastole, a period of myocardial relaxation rest is therefore about 5 l/minute. This varies
when the heart fills with blood, and systole, from individual to individual depending on
a period of myocardial contraction when body size: the larger the person, usually the
blood is pumped out of the ventricles. higher the cardiac output.

a) Heart rate and rhythm:

the higher the heart rate,
the greater the cardiac output.
Rate/min
b) Stroke volume:
the greater the stroke volume,
the greater the cardiac output

3.5 Factors Affecting Cardiac Output

contractility

afterload=
preload= resistance
filling pressure

right side CVP 5 - 10 mmHg (M) right side PAP 30/15 mmHg
left side PCWP 5 - 15 mmHg (M) left side ART 120/80 mmHg

There are three factors that influence the is, the degree to which the myocardium is
stroke volume and the function of the heart: stretched before it contracts (filling pres-
preload, myocardial contractility and sure).
afterload.
Contractility
Preload The greater the volume of blood present
Preload is the amount of blood that is before the actual contraction, the greater the
present in the ventricles prior to systole; that stretch of the myocardial fiber and thereaf-

18 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
ter also the contraction. If the heart muscle pumped. The higher the resistance, the
is stretched too much, it does not contract as smaller the amount of blood pumped out of
effectively as at lower volumes. the heart will be (i.e. the stroke volume).

Afterload
Afterload is the resistance of the systemic
circulation against which the blood is

Tasks 3 Circulation
Q1. What are the main tasks of circulation?

Q2. Name the three elements of the circulatory system. What are their functions?

Q3. Add the names of the various parts of the heart to the diagram below.

Q4. What does ECG stand for and what does it record?

Q5. What is the heart muscle called?

Q7. What is cardiac output (C.O.) and what does it indicate?

Q8. If the SV of an adult at rest is 70 ml and their heart rate is 70 beats per minute what is
their C.O.?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 19
4 OXYGENATION

The system delivering the oxygen into the cardiovascular system must be functioning
body consists of the lungs (correct ventila- to ensure adequate blood flow to the tissues,
tion) and the cardiovascular system (the and that cellular uptake and utilization of
heart function and circulation). oxygen are not blocked.

In order for oxygen to be successfully The following table lists some of the ques-
delivered to the tissues, an adequate amount tions pertaining to tissue oxygenation, as
of deoxygenated hemoglobin must be well as their respective phases in the ‘‘vital
available to bind and carry the oxygen. The logistics process’’:

Question Phase

Does enough gas reach the lungs? ventilation

Is it evenly distributed? ventilation
Does enough oxygen reach the alveoli? ventilation
Does enough oxygen diffuse into the blood? diffusion
Can the blood receive enough oxygen? lung perfusion/uptake
Does the blood go where it should? circulation/perfusion
Can the blood release the oxygen to the tissues? oxygenation/Hb dissociation
Can the tissue cells use the oxygen to produce energy? metabolism

Tasks 4 Oxygenation
Q1. Briefly describe the functions of the cardiovascular system.

Q2. What is the function of deoxygenated hemoglobin?

Q3. Why is it important that the cardiovascular system functions effectively?

20 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
5 METABOLISM
The human body is an energy machine Carbon dioxide (CO2) is released as a side
converting food to mechanical work and product. This process is called oxidation.
heat. For fuel the cells need oxygen (O2). Excess CO2 is quickly removed by ventilation.

Nutrients Energy
+ Oxidation +
O2 CO2

For the oxidation process to be efficient, production, which is less efficient and
both O2 and nutrients need to be inside the causes lactic acid production and eventually
cell. A lack of oxygen in an otherwise lactic acidosis12.
functioning cell leads to anaerobic energy

Even if O2 is supplied sufficiently, lack of

heat (energy) glucose in the cell (e.g. non-treated diabetes
CO2 mellitus) will prevent normal energy produc-
CO2
CO2 tion.

Glucose is a sugar that is produced from

carbohydrates (e.g. in rice or cereals or cane
sugar) and also through biochemical reac-
tions in the body.
.
Oxygen consumption (VO2) and carbon
.
dioxide production (VCO2) in the body are
directly proportional to the amount of
energy produced at the cell level.
glucose + O2

12
acidosis =
an increase in hydrogen
ion concentration
(decrease in pH).

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 21
 CO2

CO2 O2

20 1
O2

CO2

Pulmonary gas exchange is equal to cellular expenditure for the adult male is 2550 kcal
gas exchange, whenever the status of gas (10,600 kJ) and for a female 1950 kcal (8100 kJ).
buffers13 in the blood is stable. As the buffer
for CO2 is 20 times bigger than the buffer for Diseases and different clinical conditions
O2, changes in the cellular gas exchange may have a significant effect on energy
level are more rapidly reflected in pulmo- requirements and thus energy expenditure
. .
nary VO2 than in pulmonary VCO2. Normal (EE), for example in the case of a critically ill
basal oxygen consumption is about 250 ml/ patient. Temporary increases of up to 200%
min and carbon dioxide production about can occur due to e.g. shivering and convul-
200 ml/min. sions. Hypermetabolism, e.g. in injury and
infection, may increase the energy expendi-
Energy Requirements ture in extreme cases up to 100%. In hypo-
thermia14 and circulatory shock energy
Energy is commonly measured in kilocalo-
expenditure may decline.
ries (kcal) or kiloJoules (kJ) (1 kcal = 4.19 kJ).
An estimate of an average daily energy

% above 60
predicted
50

40

30

20

10

Injury, Anxiety Fever Work of

Infection breathing
13
buffer =
a chemical system that
prevents change in the
concentration of another
chemical substance

14
hypothermia =
below normal body
temperature

22 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Nutrition Protein
Balanced, adequate nutrition is essential The main sources of protein include meat,
for the production and maintenance of the fish and dairy products. Protein is continu-
gross mass of body tissue, for the support of ously being broken down in the body and
vital activities, and for recovery from illness must be continually replaced.
and injury. The food is pre-processed
through certain steps, first to carbohydrates, The building blocks of protein are amino
fats and proteins, and further into simpler acids. When they break down nitrogen is
molecules like glucose, fatty acids and released and discharged into the urine. It is
amino acids. possible to determine whether a person is
gaining or losing protein by comparing the
Carbohydrates dietary nitrogen intake with the nitrogen
discharged.
The principal source of energy in most diets
is carbohydrates. If the diet is low in carbo-
Within the cell, the metabolic process is
hydrates, a greater percentage of dietary
controlled by the cell nucleus. Glucose, fatty
protein is used to provide glucose, which
acids and amino acids are used to produce
means less is available for the growth and
energy, carbon dioxide, other building mate-
repair of body tissues. There are two main
rial for the cell and waste products.
types of carbohydrate in the diet: starch (e.g.
rice) and sugars (e.g. glucose). Their main
function is to provide a source of energy
which is relatively easily used by the cells.

Fat
The main functions of fat as a nutrient
are to provide a concentrated source of
energy, act as a carrier for fat-soluble
vitamins and to provide essential fatty
acids, important in the formation of cell
membranes, particularly in nerve tissue.
The main sources of fat in a normal diet
are meat products, dairy products and oils.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 23
 Cell Metabolism

Nutrients Products

Nucleus
Energy
Carbohydrates
Glucose CO2
Fats Fatty acids Building
Proteins Amino acids material
O2 Waste products

When processing substrates15 the amounts whether the person is being fed adequately
of oxygen consumed and carbon dioxide or gaining weight. Also the amount of
produced vary according to the type of energy released by different substrates
substrate. The ratio between carbon dioxide varies. For example 1 g of fat releases more
production and oxygen consumption, the than twice as much energy as 1 g of protein
respiratory quotient (RQ), reveals the main or carbohydrate.
substrate that is being metabolized and

RQ Energy / g
> 1.0 overfeeding
1.0 carbohydrates 4.31 kcal (glucose)
0.83 proteins 4.1 kcal
0.71 fat 9.3 kcal
< 0.7 starvation

15
substrate =
a substance upon which an
enzyme acts

24 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 5 Metabolism
Q1. What is the oxidation process, what is a by-product of this process and what is a quick
way to remove if from the body?

.
Q2. Why are changes in .the cellular gas exchange level more pronounced in pulmonary VO2
than in pulmonary VCO2?

Q3. Give three examples of contributors to increases in energy expenditure (EE) and by
how much they may effect our energy expenditure.

Q4. What is the “RQ” and what does the RQ tell us?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 25
6 NEUROPHYSIOLOGY
6.1 The Nervous System
The nervous system acts as the control the spinal cord, which are like the central
and communication system of the body. processor of the body: all processing of
The nervous system consists of neurons, information takes place here.
which communicate with each other by
sending electrical impulses called action The PNS consists of sensory and motor
potentials. neurons. Sensory neurons provide
information to the CNS and motor neurons
The nervous system consists of the central transport commands given by the CNS to
nervous system (CNS) and the peripheral the muscles. The autonomic system has
nervous system (PNS). The autonomic two branches, the sympathetic division and
nervous system is mainly located outside the the parasympathetic division. The balance
central nervous system, but is under its between them has an important role in
control. The CNS consists of the brain and the regulation of vital functions.

26 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
6.2 Brain Anatomy

Thalamus
Cortex DIENCEPHALON
Hypothalamus

CEREBRUM

Midbrain
CEREBELLUM
Pons
BRAIN STEM
Medulla
Spinal cord

POSTERIOR (BACK) ANTERIOR (FRONT)

Different parts of the brain are responsible The most interesting part of the brain is
for different functions. In general terms, the probably the cerebrum or the ‘‘big brain’’
brain stem regulates vital and other bodily especially its surface layer - the cortex,
functions (e.g. heartbeat, breathing, swallow- where all conscious thinking takes place.
ing etc.) and relays motor and sensory It consists of a network of neurons, which
impulses between other parts of the brain communicate with each other by sending
and the spinal cord. The cerebellum is impulses. When enough activity is summed
responsible for balance, whereas the dien- up, it can be measured from the scalp as a
cephalon assists in sensing and movements, small electrical voltage – much like the
and controls the autonomic nervous system. electrical activity of the heart, only ten
It is also the home of feelings. times smaller.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 27
 sensing
moving

seeing

talking

hearing

Functional area of the cerebrum

6.3 Factors Affecting Nervous Function

Neurons are very dependent on blood Brain activity also changes due to changes in
oxygen. If blood flow to the cells stops, the state of arousal and body temperature.
irreversible damage can take place in a Many drugs, e.g. anesthetics, either
matter of a few minutes. In an ischemic stimulate the central nervous system or
situation (inadequate oxygen supply), brain slow down its activity.
activity slows down and the amplitude
decreases.

Tasks 6 Neurophysiology
Q1. Why are the brain and the spinal cord regarded as the central processor of the body?

Q2. What are the main parts of the brain and what are their functions?

Q3. What does the peripheral nervous system consist of and what are its functions?

28 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
 5. oxygenation of cells
metabolism by cells

1. inspiration 2. diffusion 3. circulation

O2

6. expiration
CO2 O2

4. perfusion

3. circulation

In the following chapters we will take a closer look at anesthesia and critical care
as processes, and the equipment and monitoring parameters related to patient care.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 29
7 THE ANESTHESIA PROCESS

Venue: Operating Room (OR)/Operating Theater (OT)

Major Roles: Surgeon, Patient, Anesthetist, Hospital Administration
Other Players: Other Staff

While full recovery of the patient is of obvious importance to all the players,
their focus may vary:

Operating Surgeon Stable & relaxed site to operate in;

“Don’t move, don’t twitch...” successful operation
Patient Avoid pain; get well soon
“No pain, no horrors...zzz”
Hospital Administration Short stay in OR, Post Anesthesia Care Unit
“Look at these costs...” and ward; low-cost operation
Anesthetist Combine all the above interests ➝ provide high
“And I have to please them all...” quality, safe and cost-efficient anesthesia

30 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
7.1 General Overview
Anesthesia enables surgical operations and mean the state into which a patient is
diagnostic or therapeutic procedures to be rendered to enable a surgical procedure to
performed without pain, comfortably and take place without pain. Depending on the
safely. The word anesthesia originates from type of procedure, consciousness and
the Greek word meaning ‘‘insensitivity to memory may be absent as well.
pain’’. In modern medicine it is taken to

Different types of anesthesia are defined as follows:

Local Regional General

1. Local anesthesia applies the local The goals of general anesthesia are often
anesthetic directly to an area, e.g. for the expressed by the following components:
removal of a mole.
1) Analgesia: pain relief
2. Regional anesthesia applies the local 2) Unconsciousness
anesthetic to nerves innervating a certain 3) Amnesia: lack of memory of surgical
region, e.g. for operating on a knee or an experience
elbow. Local and regional anesthesia provide 4) Muscle relaxation: immobilization of the
analgesia (pain relief) and some degree of surgical area
muscle relaxation (immobility)
at the operating site without loss of These goals may be reached by using either
consciousness. intravenous and/or inhalational anesthetics.
In the intravenous method (TIVA = total
3. General anesthesia is needed when it is intravenous anesthesia), drugs are injected
beneficial for both the patient and the surgical into the patient whereas inhalational
procedure that the patient is unconscious anesthesia is achieved by introducing
during the operation and unable to recall anesthetic agents to the air breathed in by
events immediately prior to it. Types of the patient.
operations requiring general anesthesia
range from appendix removal to open heart
surgery.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 31
7.2 Historical Review
The development of modern anesthesiology started more than 150 years ago with the first
general anesthesia administered in 1846. Even before that several discoveries, starting from
the late 1700s, also contributed to the evolution of anesthesia:

Discovery of oxygen 1770s

Nitrous oxide as “laughing gas” 1808
Discovery of morphine 1800s
Non-anesthetic use of ether & chloroform 1800s
First general anesthesia (with ether) 1846
Main blood groups: transfusion of blood 1900s
Aseptics 1900s
First intravenous anesthesia 1932
Neuromuscular blocking agents 1942 -
Manually controlled breathing 1940s
Modern inhaled anesthetics 1956 -

7.3 Phases of Anesthesia

This guide will concentrate on general to flying, and the flight comprises three
anesthesia, but all types of anesthesia can be phases: take-off, level flight and landing. The
thought of as processes comprising the riskiest phases of flying are take-off and
following chronological parts: landing, and the same applies to anesthesia.
Observation of the patient’s ventilation,
General anesthesia is often compared to circulation and oxygenation is vital to the
flying an airplane. The pilot plans the flight whole process.
route, carefully inspects his plane just prior

32 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Preoperative Assessment
Any surgical procedure or anesthetic condi-
tion poses a risk to the patient. Therefore a
preoperative assessment is required to
estimate the risks of surgery and anesthesia,
and to balance them against the benefits of
the proposed operation. It covers the patient’s
status evaluated from a physical examina-
tion and history: general condition, back-
ground diseases, current medication, general
anatomical and physiological status and
mental status.

Laboratory and X-ray investigations provide

the anesthesiologist with additional informa-
tion to help plan the anesthesia.

The above enables the anesthesiologist to

determine the patient’s physical status (ASA
class): the higher the grade, the higher the
risk of an adverse reaction to the combina-
tion of anesthesia and surgery.

Patient Classification
ASA 1 Healthy, normal, aged below 65
ASA 2 Mild systemic disease (e.g. mild hypertension) or healthy, normal, aged over 65
ASA 3 Moderate systemic disease limiting normal activity (e.g. diabetes)
ASA 4 Severe systemic disease which is a constant threat to life
ASA 5 Moribund, not expected to live 24 hours with or without the operation
ASA (1-5E) Signifies that the operation is to be performed as an emergency.
This places the patient in the next level.

The number of relatively low-risk operations anesthesia based on the patient’s status and
is high. High-risk operations are performed risk assessment as well as on discussions
in fewer hospitals than low risk operations. with the surgeon(s),
The anesthesiologist selects a strategy for

Number of Small Hospitals

Operations
Medium-Sized Hospitals

“University Clinics”
Risk Level

I II III IV V ASA Class

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 33
Preoperative Preparation
A final evaluation and preparation for the
operation is made well before surgery.
Premedication is prescribed if appropriate.

Preoperative fasting is important to avoid

life-threatening aspiration pneumonitis
(inflammation in the lungs), due to possible
regurgitation of gastric contents in an
unconscious patient.

In emergency operations, the anesthetic risk

is markedly increased: the patient has not
been fasting and preoperative assessment
and preparation are limited.

All the OR equipment used is carefully

checked before the patient is brought in.

Induction
Induction of anesthesia is the beginning of
the anesthetic procedure. It is usually
preceded by the placement of a venous
catheter for injecting fluids, anesthetics and
emergency drugs. The normal site for
cannulation is a peripheral vein of the hand
or arm. Sometimes when the peripheral
veins cannot be accessed, a more central
vein such as the jugular vein in the neck
may be used.

Intravenous induction is more typical for

adults, whereas inhalation by facemask is
commonly used for children. The induction
agents will anesthetize the patient rapidly.

34 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Intubation
It is often necessary to ventilate the patient During intubation, the patient is sufficiently
mechanically to compensate for the depres- relaxed and not breathing. To prepare the
sant effects of the anesthetics (for sleep), patient for intubation, pure oxygen is nor-
analgesics (for pain removal) and neuromus- mally administered to help prevent oxygen
cular blocking agents (NMBAs, for muscle depletion (hypoxia). This is called
relaxation) on ventilation. It is thus necessary preoxygenation, during which time the
to insert a tube into the trachea through the monitoring of expiratory O2 (EtO2) and
mouth or a nostril and to connect its other the difference between the inspiratory and
end to the ventilator. This procedure is expiratory O2 (I-E O2) helps to determine the
called intubation and the tube is called the adequacy of oxygen reserves and thus the
endotracheal tube (ET-tube). correct time for intubation.

cuff
endotracheal tube

Tubes for adults have an

inflatable cuff which
inhibits leaks and helps
to prevent regurgitated
stomach contents from
entering the lungs.

There are several possible complications Immediately following intubation the patient
that can occurduring intubation: according is usually connected to a ventilator. This
to a study referred to in the European takes over the task of breathing for the
Journal of Anaesthesiology, roughly unconscious patient, whose respiratory
40% of all damaging respiratory events functions are impaired. When intubation is
during anesthesia are related to intubation. not considered necessary, the patient’s
breathing can be assisted by mask ventilation.
Some of the most common complications
include placing the tube into the esophagus During surgery and anesthesia, the patient is
instead of into the trachea, or pushing it too positioned to offer optimal exposure of the
far, into the right bronchus. Obstructions surgical field. A desirable position, however,
in the tube (e.g. mucus, blood) and may cause impaired venous return to the
laryngospasms (closure of the larynx and heart or interfere with the ventilation of the
inability to intubate) may also occur. Most of lungs.
them can be prevented by adequate monitor-
ing of ventilatory parameters such as expira-
tory CO2 (EtCO2) and the airway pressures and
volumes.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 35
 Anesthetic Gases
The gas delivered by an anesthesia delivery
unit (with ventilator) is a mixture of oxygen,
nitrous oxide or air and anesthetic agents.
Nitrous oxide (N2O) is a weak gaseous
anesthetic which is used as a traditional
anesthetic agent supplement and has few
reported side effects. It supplements the
effects of other anesthetic agents, which are
then needed in lower concentrations.

Maintenance
The main goal of the maintenance phase is
to manage the patient’s ventilation, circula-
tion and oxygenation as well as to maintain
adequate anesthesia. The anesthesiologist
observes and adjusts the functions of the
vital systems, substituting his or her exper-
tise for the mechanisms that ordinarily
maintain this delicate balance.

Of all the phases of anesthesia, the mainte-

nance phase is the most stable, but still
requires constant watchfulness. High-quality
monitoring of the parameters related to
ventilation, circulation, oxygenation and the
anesthetic effect allows fast response to
undesirable changes.

Emergence from Anesthesia

At the end of the surgical procedure the
administration of anesthetic agents is
stopped. They either start washing out of the
body with every expiration, or become
metabolized. The anesthesiologist can, by
proper administration, eliminate the effects
of all the drugs used.

Reversal agents can be used to antagonize16

the effects of certain drugs, e.g. to restore
the muscle power that is required for sponta-
neous breathing.

16
antagonize = Spontaneous breathing can be assessed
"overthrow" by measuring the amount of minute
17
minute ventilation = ventilation17 (MV) and EtCO218.
minute volume

18
EtCO2 =
end-tidal CO2 =
end-expiratory CO2
concentration

36 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Oxygenation of the patient during this phase
is advisable to prevent hypoxemia19 as the
anesthetic agents are washed out. The
monitoring of the expiratory concentrations
of anesthetic agents helps to predict the
moment of emergence from anesthesia.

Unlike the maintenance phase, the goal here

is to induce change (restoration of breathing
and consciousness), while still maintaining
the balance of the vital functions. Conse-
quently, this phase is a complex one and as
risky as the induction phase.

Recovery
Recovery from anesthesia is a critical
period. It is at this time that many
anesthesia-related complications occur:
restoration of breathing may be delayed due
to the respiratory depression caused by
anesthetics, analgesics and NMBAs. Possible
hypothermia with consequent shivering of
the muscles may lengthen the recovery time.

According to international accident studies

transportation of the patient from the
operating room to the recovery room repre-
sents a major risk. The monitoring of the
patient’s vital functions is very important but
still often neglected during this phase.

After the surgical procedure and when

emergence from anesthesia is in progress,
the patient is most often taken from the
operating theatre to a separate area where
emergence is completed and the patient is
carefully monitored. This area is called
the Post-Anesthesia Care Unit (PACU) or
Recovery Room.

19
hypoxemia =
diminished amount of
oxygen in the arterial blood

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 37
7.4 Drugs During Anesthesia

Analgesia Relaxation Amnesia Unconsciousness

?
? ?
?

The goals of anesthesia can be reached with the help of various drugs.

Premedication
The purpose of premedication, administered or intravenous anesthetic. Normally
30-60 minutes before starting anesthesia, is inhalational induction is used with children,
to remove fear and anxiety. whereas with adults, intravenous drugs such
as thiopental and propofol are the most
Drugs to remove fear and anxiety include commonly used.
benzodiazepines, barbiturates and opioids.
In addition to their desired effects they may During induction, administration of intrave-
depress the respiratory system. nous analgesics (for pain removal) and
NMBAs typically begins simultaneously with
Drugs for Inducing Anesthesia anesthetics. NMBAs facilitate tracheal
Vagolytics to protect the heart from the intubation and further muscle relaxation in
depressant effects of anesthetic agents thoracic, abdominal and certain other kinds
include atropine and glycopyrrolate. They of surgery. Adverse side effects of induction
also reduce airway and gastric secretions agents may include respiratory depression
and sweating, but may cause unwanted and decreased blood pressure.
changes in heart rhythm. Vagolytics are
administered first, prior to induction. Inhalational anesthetic agents are: haloth-
ane, enflurane, isoflurane, sevoflurane and
The goal of induction is to put the patient to desflurane together with N2O. These are
sleep. This can be done using an inhalational described more fully in section 9.3.

38 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Drugs during
the Maintenance Phase
The goals of the maintenance phase of
anesthesia are keeping the patient uncon-
scious, free from pain and immobile. During
the maintenance phase, three kinds of drugs
can be given to the patient:

EXAMPLES
Inhalational anesthetics Anesthetics

Intravenous anesthetics
- thiopental
- propofol
- etomidate
- ketamine

- fentanyl Analgesics
- alfentanyl
- sufentanil

potentiate20 the anesthetic effects of

intravenous and inhaled anesthetic agents.

- (succinylcholine) Neuromuscular blocking agents

- atracurium
- rocuronium
- pancuronium
- vecuronium
- mivacurium

potentiated by inhaled anesthetic agents.

Drugs at the End of Anesthesia

Emergence and recovery from anesthesia
should be predictable and carefully control-
led. As some drugs affect the patient longer
than desired, their action may be reversed
by antagonists in order to ensure the pa-
tient’s safety. The benzodiazepines may
be antagonized by flumazenil, analgesics
by naloxone and NMBAs by neostigmine
and atropine. 20
potentiate =
to enhance functional
effect

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 39
7.5 Equipment for Anesthesia Delivery
An anesthesia machine has two functions: it • flowmeters for adjustment of O2, N2O and
mixes gases (gas machine) and generates air flows (1)
positive pressure to push the mixture into • anesthetic agent vaporizers (2)
the patient’s lungs (ventilator). Components • breathing system (3) with overflow valve
of the anesthesia machine are: for scavenging (evacuation) (5)
• ventilator (4)

1 2
30% vaporized

02 AA

Air/
N20
70%
4
5
ventilator
control unit

Anesthesia machine components

Gas Delivery System

Oxygen (O2) is usually administered during which is an interface between the patient
anesthesia as a 30% concentration together and the anesthesia machine.
with 70% nitrous oxide (N2O) or air.
Breathing System
A volatile anesthetic agent (halothane,
The breathing system is a pathway for the
enflurane, isoflurane, sevoflurane or gas mixture to enter the patient (inspiratory
desflurane) is vaporized into the gas mixture limb) as well as one for the exhaled gas
when an adjusted volume of the gas flow is mixture to lead away from the patient
directed through the vaporizer. This final (expiratory limb). The flow direction of the
mixture is called the fresh gas. gas inside the breathing system (or patient
circuit) is controlled by unidirectional
The fresh gas is fed through the fresh gas valves, one in each limb. Each breathing
outlet (FGO) into the breathing system, system has a specific volume.

40 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Functionally, breathing systems can be In the non-rebreathing system gases expired
divided into rebreathing and non- by the patient are directed straight to the gas
rebreathing systems. scavenging system, which exhausts them
from the operating room.

manual ventilation
bag or ventilator
30% vaporized

02 AA

Air/
N20
scaven-
70% ging

In the rebreathing system part of the A rebreathing system with CO2 absorption
expired gases is directed back: becomes a non-rebreathing system when
• a rebreathing system without fresh gas flow exceeds the minute volume.
CO2 absorption e.g. Jackson-Rees
• a rebreathing system with
CO2 absorption e.g. Datex-Ohmeda
anesthesia machines

30%
vaporized
02
AA

42
CO
Air/
N20
70%

ventilator

In principle, from the patient’s point of view, Oxygen and anesthetic agent monitoring is
it doesn’t matter where the gas comes from as necessary in minimal and low flow
long as the mixture, temperature and humid- anesthesia so that adequate oxygenation
ity are correct. But recirculation of gases of the patient can be guaranteed and a suffi-
makes it possible to lower fresh gas consump- cient level of anesthesia maintained. Monitor-
tion. When fresh gas flow is reduced we are ing of inspiratory and expiratory concentra-
talking about low flow anesthesia and with tions of oxygen, N2O and volatile anesthetics
extremely low flows minimal flow ensures adequate fresh gas delivery during
anesthesia. anesthesia.

Low flow anesthesia enables considerable NOTE: During low flow, the gas mixture at
savings in anesthetic agent and gas consump- the FGO is not the same as is inspired! Think
tion. It is also beneficial for the patient, as re- about why.
breathed gas is warm and humid.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 41
 Anesthesia Ventilator
The ventilator is anything that generates the Pressure controlled ventilation is especially
positive pressure needed for the gas to enter useful when the airway pressure has to
the lungs. It can be the anesthesiologist’s be closely controlled, or when a leak in
hands squeezing a “bag” (manual ventila- the breathing system due to a cuffless
tion), a pneumatically driven bellows (“bag endotracheal tube, for example, has to be
in a bottle”) or a mechanically driven piston. compensated for. In this mode the maximum
In the case of manual ventilation an adjust- airway pressure delivered by the ventilator
able overflow valve is needed to adjust the is adjusted together with the respiration rate.
“tightness” of the circuit. The generated pressure results in different
tidal volumes depending on the resistance
Modern anesthesia ventilators are typically of the airway. Since adequate minute venti-
time-cycled and powered by electricity and lation is the key issue during mechanical
compressed gas, which serves as the ventila- ventilation, monitoring of normoventilation
tor driving gas between bag and bottle. is important.
The driving gas is air or oxygen. During
inspiration the driving gas passes into the Manipulation of the breathing cycle.
bellows chamber, squeezes the bellows, and The oxygenation of the patient can be
pushes the gas inside the bellows into the improved by increasing the inspiratory time,
breathing system. During expiration the inspiratory pause time or PEEP level
driving gas is vented into the room air, and (Positive End-Expiratory Pressure).
the bellows is filled with expiratory gas as Giving the alveoli more time to be
the patient exhales. expanded provides more time for O2 and
CO2 to diffuse between the alveoli and
Anesthesia Ventilation blood. An increased PEEP level keeps the
alveoli open at the end of expiration and
During anesthesia either the patient can
thus may improve patient oxygenation.
breathe spontaneously, or ventilation can be
Continuous monitoring of airway pressures,
manually assisted by squeezing a breathing
volumes and ETCO2 levels helps the
bag, or ventilation can be mechanically
anesthesiologist to better maintain adequate
controlled by the ventilator bellows. In fact,
ventilation and gas exchange.
if you think about the phases of general
anesthesia, all these modes may be present
at one stage or another. Monitoring of Fresh Gas Delivery
Monitoring of inspiratory and expiratory gas
The type of ventilation is specified by the concentrations of oxygen, nitrous oxide and
type of operation, type of anesthesia, and by anesthetic agents guides fresh gas delivery
the age and condition of the patient. The during anesthesia. The lower the amount of
patient can breathe spontaneously during fresh gases used, the more important the gas
local, regional or general anesthesia but monitoring because the rebreathed gases
when general anesthesia is administered dilute the fresh gas from the anesthesia
using drugs which severely depress respira- machine.
tion, e.g. NMBAs or opioids, the patient’s
ventilation has to be controlled. Monitoring of Ventilation
Monitoring airway pressures and volumes
Volume controlled ventilation is commonly breath-by-breath is essential for adequate
used during anesthesia. Since MV=RR x TV21, ventilation management during anesthesia.
either MV or TV are adjusted along with RR. Monitoring of expiratory carbon dioxide
Adequacy of ventilation is ensured by concentrations helps to normoventilate the
21
MV = Minute Volume
checking that end-expiratory CO2 (ETCO2) patient during mechanically controlled
RR = respiration rate indicates normoventilation. ventilation.
TV = tidal volume

42 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 7 Anesthesia Process
Q1. Write the name of the symbol under each picture.

?
? ?
?

Q2. Name the three different types of anesthesia.

Q3. Note down the six steps of the process of anesthesia in the order in which they are performed.

1. 2.

3. 4.

5. 6.

Q4. What is the beginning of the anesthetic process called?

Q5. What is monitored during preoxygenation to help determine the adequacy of O2

reserves and thus the correct time for intubation?

Q6. What happens immediately following intubation?

Q7. What is included in the mixture of gas delivered by an anesthetic delivery system?

Q8. Name the five inhalational anesthetics.

Q9. What is the standard equipment used to deliver anesthesia?

Q10. Name the two extreme kinds of patient circuit.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 43
8 THE CRITICAL CARE PROCESS
8.1 Historical Review
Critical care as a medical discipline is one of In the 1960s and early 1970s technological
the newest areas in medicine. The actual advances in aerospace engineering were
practice of critical care has, however, coupled with a tremendous increase in
been around for a lot longer. The modern- the knowledge of the pathophysiology of
day term “critical” care refers both to the critical illness. The earlier phrase “intensive
severity of the patient’s illness and the level care” is gradually being replaced by the
of intensity of care. There are more highly phrase “critical care”.
sophisticated types of technologies involved
in the care of these patients.

Critical Care: advanced and highly specialized care provided to medical or surgical
patients whose conditions are life-threatening (but not hopeless) requiring comprehen-
sive care and constant monitoring. It is usually administered in the specially-equipped
units of a healthcare facility.

8.2 Introduction to Critical Care

The practice of critical care has become a Levels of Care
science. In many cases the health care
The level of care is directly linked to how
professional is a scientist as well as a caregiver.
acute and severely ill the patient is.
Monitoring is not just confined to the
Workload in an intensive care area is linked
cardiopulmonary system but now extends to
directly to the severity of illness of the
all body systems. Diagnosis and treatment of
patient and the intensity of therapy.
life-threatening disease and the preservation
of life takes place 24 hours a day.
Intensive care units may be classified as
high, medium or low-risk units depending
Intensive Care/ on the number, specialization and availabil-
Critical Care Medicine ity of physicians, the intensity of therapy
and the nurse-to-patient ratio. Acutely and
The goal of critical care is maintaining vital severely ill patients will be placed in a
organ function and preserving life while higher risk area/unit.
treating the underlying disease. In recent
years a high degree of specialization and a Patients requiring critical care may be found
deeper understanding of the needs of in different areas of the hospital. There may
particular patients have given rise to the also be different types and combinations of
development of specialized care areas. intensive care units (see following diagram).

44 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
 Day Surgery General Surgery High-Risk Surgery
Observation Intensive Assessment Intensive Assessment Unstable Patients with
& Intensive Therapy Intensive Assessment &
Intensive Therapy

Surgical Transplant
Day Surgery Cardiac surgery surgery
Post- Recovery SICU
Room PACU
operative

Medical ED [Link], MICU

Cardiac Chest pain CCU

Trauma Unit
Trauma
Endoscopy, Radiology, CT,
Clinical X-rays MRI
Diagnostic

Classification of Critical
Care Units
There is no generally accepted nomenclature Emergency Department/Trauma Unit/
for classifying critical care units. The Casualty Ward: the primary tasks are
following matrix combines the level of care assessment, resuscitation and stabilization of
with classification of ICUs by services and patients. Patients from these areas tend to be
can be used to illustrate the segmentation in dispatched to various areas of the hospital,
critical care. the most critical going to the critical care
units.
Post Anesthesia/Recovery Room:
observation, monitoring and occasionally Neonatal/Pediatric Intensive Care: treat
ventilation of post-surgical patients. The patients at specific stages of life and admis-
most important aspects of care are that the sion criteria are therefore based on patient
patient is conscious enough to maintain an age. Most NICU areas admit patients in the
airway and that vital signs are stable after a period immediately after birth. A dedicated
surgical procedure. pediatric critical care unit will have a patient
population whose age varies between
High Dependency/High Care/Medium approximately one month up to 16 years.
ED =
Care/Intermediate Care/Step-down Unit: Emergency Department
these areas, which vary from center to Scoring Systems PACU =
center and from country to country, imply
Scoring systems have been devised in order Post Anesthesia Care Unit
the same level of care. The patient’s need for
to determine both how acutely and severely SICU =
care falls in between the level provided in Surgical Intensive
ill the patient is, and the staff workload.
the normal hospital environment and that Care Unit
These scoring systems can in some cases
provided in the critical care area. MICU =
point toward care pathways and predict Medical Intensive
outcomes of critical care patients. Care Unit
Intensive Care Unit/Intensive Therapy
CCU =
Area: in this area there is a higher degree of Cardiac Care Unit
specialization of caregivers and the technologies
MRI =
they employ to preserve vital organ function Magnetic Resonance
while correcting the initial cause of injury. Imaging

CT =
Computerized Tomography

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 45
 8.3 Critical Care Facilities
The Ideal Critical Care Unit
The ideal critical care would be one that and MRI. The longer the distance, the more
works almost like a miniature hospital with staff are needed for transportation and the
its very own services and facilities close by. more the risk of mishaps increases. In the
One of the greatest challenges in the care of ideal critical care unit essential services like
critical care patients is the transportation to laboratories, pharmacy, blood bank and
and from facilities like CT Scan, Fluoroscopy technical services are located close by.

Patient flow

Diagnostic Consultations Surgical

services services Ward
OR
Medium
RR Care

Intensive
ER Admission
➡ Care Discharge Step-down
Unit

Ward
HDU

Another
ICU Administration Pharmacy Another
hospital
Another
Hosp.
Technical Material
services services

Space and Technical Conditions

Critical care units are designed differently in regulation. Other rooms and areas must be
all parts of the world. Critical care as a attached to the critical care unit: storage
discipline is rather new. Therefore in some facilities for medical equipment, conference
of the world’s older and more established rooms and a “family room”. Many newer
hospitals the critical care units are not ideal critical care units have an area for essential
for critical care. laboratory work and also a pharmacy solely
dedicated to that particular ICU.
HDU = The physical design of a critical care unit or
High Dependency Unit
ward varies a great deal from one unit to Staffing in the Critical Care Area
OR =
another. Some are large open areas easily
Operating Room Care personnel may have had specialized
viewed from a central area, others are training in intensive care medicine. Clinical
RR =
Recovery Room individual rooms or cubicles. The physical support service staff may include: clinical
design has an effect on cross-infection dieticians, respiratory therapists, radiology
ER =
Emergency Room between patients, distraction, distress, technicians, biomedical technicians, occupa-
privacy, staff communication, visual moni- tional therapists, physical therapists, clinical
ICU =
Intensive Care Unit toring, infection control and temperature pharmacists and laboratory technicians.

46 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Additional services may be provided by sional. The critical care area is one of the
social workers, ward clerks or ward secretar- busiest and most demanding areas in the
ies, nurses’ assistants and orderlies as well as hospital. The combination of in-depth
religious care workers. patient care, sophisticated life support
systems and the need to interact with many
Physicians in Critical Care other healthcare professionals requires that
the modern critical care nurse is a multi-
The physician working in critical care may
skilled practitioner. A prerequisite is an
have a varied educational background.
acute understanding of the clinical needs of
Originally many ICU physicians were
the critical care patient and the ability to
anesthesiologists and in many parts of the
rapidly assess monitored information and
world they still are. Physicians from a
apply nursing knowledge and intuition to
variety of disciplines practice critical care. In
the patient care process.
some countries critical care medicine is a
specialty. However, those working in the
area generally have another area of exper- Respiratory Therapists
tise, e.g. pulmonology, infectious disease or in Critical Care
anesthesia. Whatever the educational
Respiratory therapists also play a role in
background, the doctor working in the ICU
critical care. The job may include some or all
has the unique task of having to consider the
of the following duties: assisting in intuba-
effect of his decisions on all body systems
tion, performing intubation/extubation,
while trying to preserve life. All of this is
patient transport, bloodgas procurement and
done under what are often very trying
analysis, hemodynamic monitoring, me-
circumstances.
chanical ventilation adjustments, arterial
line placement, chest physiotherapy and
Nurses in Critical Care oxygen therapy.
In some respects nurses in the ICU are seen
as a different “breed” of health care profes-

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 47
8.4 Phases of Critical Care
The critical care process is very complicated. certain steps in the care process of the
The patient care process changes in critical care patient that can be applied
response to the improvement or worsening with little variation to almost any hospital
of patient condition. However, there are area.

Critical Care
Process
Surgical
Intensive Care
Perioperative
Process Treating vital
functions

Analyzing
disorder Rehabilitation
Intensive
Care
Preventing Treating the
additional main disease
damage
Nursing care

Cardiac Care

Admission The patient is resuscitated (if needed),

All patients must go through some form of stabilized and moved to critical care for
admission process in order to be admitted to monitoring, investigation, further treatment
a critical care area. Pre-arranged or planned and rehabilitation. Admission to a critical
cases include certain types of surgery, i.e. care area can be due to virtually any disease
major thoracic surgery or neurological which is currently compromising, or will
surgery where monitoring and ventilatory very soon compromise, the patient’s ability
support may be required for a longer period to maintain vital organ function.
of time. In post-operative cardiac critical
care, for example, almost all patients have Aspects of Care and Observation
been admitted prior to surgery and received Restoration and Maintenance of Vital
directly after surgery. Organ Function
The goals of every level of critical care are
A large number of cases are admitted with- preserving life and treating underlying
out prior planning, usually from an emer- disease. The methods used attempt to
gency department or some other hospital optimize tissue oxygenation and allow
area where the patient’s condition has adequate removal of carbon dioxide. Treat-
become critical. The screening of these ing disease in the critical care area requires
patients is done by critical care staff with complex drug and fluid therapies combined
primary care givers and very often patient with mechanical interventions. Maintaining
family members are consulted. adequate nutrition for the patient often

48 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
requires the use of enteral and parenteral Adjuncts to Patient Care
feeding methods. Enteral feeding, “tube There are many monitoring, imaging and
feeding”, is preferred when the patient’s diagnostic tools at the disposal of critical
gastrointestinal tract is functioning. There care personnel. These include patient
are times when there is a reason to adminis- bedside and central station monitors, labora-
ter nutrients directly to the patient through tory investigations, routine drug screening,
an intravenous catheter (Total Parenteral and radiological and medical imaging tests.
Nutrition or TPN (PN)). The need for skilled There is also a need for metabolic monitor-
nutritional assessment is extremely acute in ing to assess the patient’s nutritional require-
the critical care unit. It has been shown that ments so he or she can be fed properly.
adequate nutritional assessment and admin-
istration can reduce the length of the pa- Prevention of Additional Damage
tient’s stay in critical Care and save costs Although the goal of any critical care treat-
both in the long and short term. ment is to improve patient condition, many
risks exist. Adverse drug reactions, loss of
Treatment of the Main Disease blood during invasive procedures, lung
The underlying or main disease is treated damage during mechanical ventilation and
with either medical or surgical interventions patient acquisition of nosocomial (originat-
and it is common for patients to be moved to ing in the hospital) infection are only a few
an operating theater, CT scanners, MRIs and of the risks associated with the critical care
angiography22 rooms and back again to the area. For these reasons there are strict
critical care area many times. There are also procedures regarding the placement and
rare cases where time is the treatment and monitoring of invasive lines, setting of
life support must be continued until the alarms on monitors and ventilators, and
disease has run its course. protocols for the isolation of patients and the
hygiene of staff. There are also rules for the
Nursing Care sterilization of equipment, patient areas and
The relationship between the critical care the removal and disposal of infected mate-
nurse and patient is the most constant and rial.
with a few exceptions it can be one of the
closest of all possible care giver – patient Documentation
relationships. The bedside nurse is generally A patient chart which is signed by the
the first to ascertain whether a selected physician is used to document treatments,
treatment has the desired effect on the and to record test results and chart pharma-
patient’s condition. This is done by cological protocols. The patient chart is also
listening, watching and feeling the patient. used to record nursing observations, the
Nursing care consists of assessment and recommendations and observations of
development of nursing diagnosis, nursing consultants, and the patient history. In most
care planning, and contributing to the critical care units there is a bedside flow
development of overall patient care plan- sheet on which the nurse records the hourly
ning. Normal duties also include setting progress of the patient. The items which
goals, following certain care protocols, have a direct bearing on patient care include
evaluating patient therapies and temperature, heart rate, blood pressure,
administering care according to the drugs administered and patient response to
instructions of the medical staff. There is the drugs. There are also areas for recording
also the aspect of maintaining a liaison with ventilator settings, blood gas values, patient
the patient’s familily and the evaluation of position, transportation to services, location
the psychological and social implications of of invasive lines, routine wound care and
the sick and dying patient. These tasks run location of bed-sores and ulcers. Generally, a
parallel to the main task of actual patient new patient chart is started every 24 hours. 22
angiography =
the radiographic
care, which is always the most important Keeping track of so many different items of visualization of blood
duty of the critical care nurse. data is quite a task. Computerized informa- vessels

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 49
tion management and record-keeping count different philosophies: e.g. social,
systems are needed to decrease workload financial and religious beliefs can play a part
and assure safety and accuracy in the patient in who obtains care in a critical care unit as
care process. well as what kind of care is given. “Quality
of life”, “patient dignity” and the overall
Ethical Considerations in Critical Care prognosis of the patient must be considered.
Deciding who is admitted to critical care is
often a very complex part of the process. Discharge
The screening process which deals with Patients are transferred to normal wards,
assessment of a patient’s need and benefits medium-care units or to the ICU of another
from critical care must also take into ac- hospital as soon as possible.

8.5 Monitoring and Equipment Used During

Critical Care
The equipment used in critical care
consists of:
• ventilators • dialysers
• infusion pumps and syringe pumps • fluid warmers
• suctioning devices • patient warming devices
• patient monitors, modular or separate. • separate analyzers for e.g. blood gases
Parameters to be monitored are • special devices to support circulation
hemodynamic parameters, ventilatory • patient humidification devices
parameters, gas exchange, metabolic • breathing system with bacterial/viral filter
measurements as option

50 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
 Monitor
Monitor
Ventilator Other Ventilator
Other equipment
equipment

Anesthesia Critical Care

Consult. Assessment Assessment
Consult.

X-ray Lab. X-ray

Laboratories

Information Sources Monitoring

Compared to other information sources in The monitoring parameters are adjusted to
the ICU, the monitors have a much smaller suit the level of care and the type of patient.
role than in anesthesia as a source of infor- The following matrix describes the monitor-
mation on which to base treatment deci- ing parameters associated with different
sions. types of patients and different levels of care.

Typical Monitoring Needs

Day Surgery General Surgery High-Risk Surgery
Observation Intensive Assessment Intensive Assessment Unstable Patients with
& Intensive Therapy Intensive Assessment &
Intensive Therapy

ECG, SpO2, Temp, ST, [Link](1), CO2, O2, [Link](3), C.O., SvO ,
Surgical NIBP + AA, NMT, (Spiro), (EEG) + Spiro, Tono, EEG, EP2 + metab.

Post- ECG, SpO2, Temp, ST, [Link](1), CO2, O2, [Link](3), C.O., SvO2,
operative NIBP + AA, NMT, (Spiro), (EEG) + NMT, Spiro, Tono, + metab.
EEG, EP

Medical ECG, SpO2, Temp, + ST, [Link](1), CO2, O2, + [Link](3), C.O., SvO2, + metab., NMT
NIBP AA, NMT, (Spiro), (EEG) Spiro, Tono, EEG, EP
Temp, 12 leads,
ECG, SpO2, ST,
Cardiac NIBP
+ Arrhythmias, + [Link](3), C.O., SvO2,
Spiro, Tono, EEG, EP
+ metab.
[Link](1), CO2
ECG, SpO2, Temp, + ST, [Link](1), CO2 + [Link](3), C.O., SvO2, + metab., NMT
Trauma NIBP (Spiro), (EEG) Spiro, Tono, EP

Clinical ECG, SpO2, Temp, + ST, [Link](1), CO2 + [Link](3), SvO2, CO2 + CCO, metab.
Diagnostic NIBP Spiro

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 51
 Monitoring needs differ from patient to and a deviation from the norm is quickly
patient, but with severely ill patients all noticed by a nurse. Alarms are used to warn
available monitoring parameters are in use. of a sudden life-threatening event such as
cardiac arrest23, serious arrhythmias24,
Because the vital functions of the patient in circulatory collapse25, etc. In some ICUs, the
the ICU are almost totally supported - alarms are routinely used as therapeutic
mechanical ventilation, drugs for circulatory guidelines: “keep the arterial blood pressure
support - the monitored values are artifi- under a certain limit with a certain drug”. In
cially maintained within normal ranges. lower-level ICUs the patient may be left
This means that a normal parameter value alone for short periods and the alarms are
may not mean that the patient is doing well, used to inform of unexpected deviations. In
the patient is dependent on the life support- this case the alarms should be communi-
ing care activities. cated over a wider area in the ICU. In these
ICUs, central monitoring may be expected to
In high-level ICUs, the patient and moni- be available.
tored values are under constant surveillance

23
cardiac arrest =
complete cessation of the
heart’s activity

24
arrhythmia =
any deviation from the
heart’s normal rhythm

25
circulatory collapse =
a state of extreme
exhaustion and depression,
with failure of circulation

52 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
8.6 Ventilation in Critical Care

The main purpose of a critical care ventila- ventilator and hospital staff were specially
tor is to provide ventilation support for those trained to use it. It became world-famous.
patients who cannot breathe on their own or In the last ten years there has been rapid
who require assistance to maintain adequate development of new technology and
ventilation. Mechanical ventilation is an features in the critical care ventilator. Now
essential part of the care of many critically ventilators support spontaneous breathing
ill patients. and include advanced monitoring features
and information networking which makes
The ventilator delivers air and oxygen at the ventilator far more safe and comfortable
positive pressure. This supports gas ex- for both patients and staff.
change, opens or maintains ventilation of
alveoli where gas exchange occurs, and Indication for Mechanical
allows the ventilatory muscles to rest until
the patient is able to breathe independently. Ventilation
• Ventilatory failure patients whose lungs
The ventilators on the market vary in terms cannot provide an adequate exchange of
of how they control the ventilation and how gases. This is reflected in the arterial
they detect changes in the patient or the blood gases. To make appropriate thera-
equipment status. Generally, all modern peutic decisions the clinician should
critical care ventilators can perform the decide whether the patient has a problem
same basic functions, but the models vary with ventilation or oxygenation, or a
widely in their capabilities and features. combination of the two.

• Impending or existing respiratory failure.

Ventilation History It is also indicated after major surgery and
In the fifties there was a polio epidemic in for therapeutic ventilation in the presence
Scandinavia and 90 % of the patients died of intracranial26 hypertension27.
even when the iron lung was used. This was
convincing proof of the need for improve- It must be remembered that the application
ment in the ventilation care of patients with of mechanical ventilation does not correct
partial or total breathing paralysis. the underlying disorder. It only supports the 26
intracranial =
within the skull
respiratory system until the appropriate
The Swedish physicist Carl-Gunnar therapies can be applied to cure the underly- 27
hypertension =
abnormally high arterial
Engström developed the volume-controlled ing disease. blood pressure

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 53
Goals of Ventilator Treatments
• Remove CO2 which is produced in the cells
• Oxygenate the blood
• Humidify airways
• Support spontaneous ventilation

Normal Settings
Respiratory rate (RR) 10 - 20 breaths/min.
(RR x VT = Minute volume)
Inspiratory-to-Expiratory Ratio (I:E) is the
duration of inspiration in comparison with
expiration. Generally the I:E ratio is set at
1:2, that is 1/3 of the respiratory cycle is
spent in inspiration and 2/3 in expiration.
Carl-Gunnar Engström
Tidal volume (VT) 5 - 8 ml/kg (body weight)
PEEP 5-10 cmH2O
O2 21-100 %

Positive End Expiratory Pressure VCV (Volume Controlled Ventilation) is a

mode for patients without breathing capac-
(PEEP) ity. VCV mode ensures that the set tidal
Positive end expiratory pressure is an
volume is delivered during inspiration, but if
application of a constant, positive pressure
the patient tries to breathe spontaneously,
in the airways. This means that, at end-
unsynchronized with the ventilator, it will
expiration, the pressure inside the lungs is
be seen as a disturbance on the pressure
never allowed to return to atmospheric
trace. Until recently, VCV was one of the
pressure. PEEP is usually measured in
most commonly used modes.
centimeters of H2O. Normal setting are 5-10
cmH2O. PEEP decreases intrapulmonary
PCV (Pressure Controlled Ventilation) is
shunting, increases the functional residual
also a mode for patients without breathing
capacity (FRC), improves compliance,
capacity. PCV regulates flow to attain and
decreases the diffusion distance for oxygen,
sustain maximum inspiratory pressure level.
and improves oxygenation.
Flow depends on airway pressure and lung
compliance, and will normally be high at
Ventilation Modes the beginning of the breath, and then
There are many methods by which the decelerate close to zero at the end of inspira-
patient and the ventilator interact to perform tion.
the ventilatory cycle. These variable tech-
niques are called modes of mechanical The PCV mode is for example suitable for
ventilation. The number of modes continues patients with a lot of leakage at the tracheal
to be increased in the effort to improve the tube and patients with lung compartments
efficiency of mechanical ventilation. The with different resistance/compliance. This
various modes of ventilation give the clini- means that the tidal volume may vary due to
cian the opportunity to change the therapy changes in airway pressure, resistance and
when the patient´s condition changes. compliance. PCV is one of the most common
ventilation modes for adults and is also often
Confusion about different modes is caused used for children.
by the fact that various authors and manu-
facturers use different terms to describe the SIMV (Synchronized Intermittent Manda-
same functional mode. tory Ventilation) is similar to Intermittent

54 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Mandatory Ventilation (IMV). The ventilator The primary advantage of CPAP is that it
attempts to deliver mandatory breaths in reduces atelectasis28. It also maintains and
synchrony with the patient’s inspiratory promotes respiratory muscle strength
effort. If no inspiratory effort is detected, the because the patient is given no other
ventilator delivers a mandatory breath at the ventilatory assistance and therefore does all
scheduled time. the work of breathing (WOB).

Volume/Pressure support is a mode of APRV (Airway Pressure Release Ventila-

ventilation in which the patient’s spontane- tion) is two levels of CPAP that are applied
ous respiratory activity is augmented by a for set periods of time. This mode allows
preset inspiratory positive pressure. When spontaneous breathing to occur at both
the patient starts inspiration, the pre-se- pressure levels.
lected pressure support is applied and then
held constant throughout inspiration, Weaning
thereby promoting the flow of gas into the
Weaning from mechanical ventilation is the
lungs. With the set support pressure there is
process of withdrawing the patient from
no set tidal volume. The tidal volume is
ventilatory support. As soon as the patient is
variable, being determined by the patient
placed on mechanical ventilation, plans are
effort, the amount of applied pressure
made for weaning.
support, and the compliance and resistance
of the system (patient and ventilator).
Nebulization29
CPAP (Continuous Positive Airway Inhalation allows rapid local delivery of
Pressure) is positive pressure applied drugs to the lung tissue with minimum toxic
throughout the respiratory cycle to the effect. Ultrasonically or pneumatically
spontaneously breathing patient. CPAP is for driven nebulizers can be used.
patients with some, but still not enough,
respiratory capacity. It can be used during
weaning since the pressure support can be
added.

28
atelectasis =
portion of lungs that has
collapsed

29
nebulization =
delivery of drug through
airways

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 55
Tasks 8 Critical Care Process
Q1. What is the main focus of critical care?

Q2. Why should an intensive care unit be designed like a miniature hospital?

Q3. Critical care is a complex process that changes with the changing needs of the patient.
However, there are certain steps in the care process that can be applied to almost any
hospital area. What are these steps?

Q4. What does PEEP stand for and why is it used?

Q5. What is the working principle of Synchronized Intermittent Mandatory Ventilation?

Q6. What is the main difference between volume controlled and pressure
controlled ventilation?

Q7. What does weaning from the ventilator mean?

56 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
9 PATIENT MONITORING

9.13 electroencephalography

9.10 carbon dioxide

9.1 patient spirometry

9.2 patient oxygen

9.3 anesthetic agents

9.5 cardiac output

9.4 electrocardiogram

9.6 blood pressures

9.9 mixed venous
oxygen saturation

9.14 gastric tonometry

9.7 tissue
oxygenation SpO2

9.11 temperature

9.12 neuromuscular
transmissiom

9.8 gas exchange

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 57
When the patient is unable to look after his accurate and reliable patient data on the
or her own interests, the clinician’s main vital signs, in both numerical and graphical
responsibility is to ensure the well-being of form.
the patient. Traditionally, one had to rely on
the senses as well as some simple measure- Many countries have published either
ments (e.g. two fingers on the pulse), to recommendations or minimum standards to
observe the patient’s clinical status and improve patient safety. Care-dependent
decide on corrective actions. While these monitoring of relevant parameters can help
still remain the key elements in watching the clinician guarantee the vital logistics
over patients, modern technology can chain from ventilation through circulation to
improve patient safety by offering objective, oxygenation and metabolism.

9.1 Ventilation: Patient Spirometry

Diffusion of oxygen
Inspiration from alveolus to blood

AIRWAY

Diffusion of carbon
Expiration dioxide and surplus
oxygen to lungs

Alveolus and
capillary

Patient Spirometry
Patient Spirometry provides a visual tool to tion from the ventilated patient is integrated
improve ventilation in anesthesia and with other parameters on the monitoring
critical care. It helps to prevent and diagnose screen in the form of quantitative and
problems with the ventilator or endotra- graphical information.
cheal/tracheostomy tube through display of
various loops and curves. In critical cases, Information is generated from pressures,
mechanical ventilation often demands volumes and flows measured at the patient’s
repeated manipulation of ventilatory para- airway by the Datex-Ohmeda D-liteTM,
meters in order to optimize oxygen delivery combined gas sampler and pressure/flow
and carbon dioxide removal. The informa- sensor.

58 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Quantitative Information
Tidal Volume (TV) and Minute Volume Compliance (Compl) is a measure of the
(MV) are the amount of gas delivered by the distendability of the lung-thoracic system
ventilator and exhaled by the patient in one and is the amount of volume change in the
breath, in one minute. There are inspired lungs per unit of pressure change of the
and expired values for both tidal volume incoming gas. Compliance is an indicator
(TVinsp, TVexp) and minute volume of efficiency of ventilation and it guides
(MVinsp, MVexp). finding optimal ventilator settings.
I:E is the ratio between inspiratory and
expiratory times. Compl = V/ P
Peak Pressure (Ppeak) is the maximum where
pressure exerted at the patient airway. V = volume increase in ml
Plateau Pressure (Pplat) is the pressure in P = pressure increase (Pplat-PEEPtot) in cmH2O
the lungs at the end of inspiration during the
period of no gas flow. Airway resistance (Raw) is the impedance
Mean Airway Pressure (Pmean) is the to gas flow in the airways. Airway resistance
average pressure measured across the entire is clinically important because of its rapid
breathing cycle. increase in certain diseases like asthma, and
also when measuring the reactivity of the
Positive End Expiratory Pressure (PEEPtot, airway and response to treatment with
PEEP) is the pressure remaining in the lung certain pulmonary drugs.
at end expiration. PEEPtot consists of two V(1.0) expresses how much of the total
components: 1) Extrinsic PEEP (PEEPe), is expired volume comes out during the first
the pressure maintained by the ventilator at second of expiration.
end-expiration. 2) Intrinsic PEEP (PEEPi),
also known as auto-PEEP, is caused by air Measuring lung mechanics continuously,
trapping in the lungs due to certain patho- breath-by-breath, is called dynamic spiro-
physiological conditions or when too short metry. In certain critical care ventilators it is
an expiration time is allowed. possible to apply inspiratory and expiratory

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 59
holds, i.e. occluding the airway for 3-5 patients mostly have healthy lungs, start-up
seconds at end inspiration and at end settings are chosen mainly based on the
expiration. This is done occasionally in patient’s demographic data. In critical care,
order to derive static spirometry values for where mechanical ventilation is typically a
Pplat, Compl and PEEPi. Static conditions means to improve the patient’s deteriorated
allow airway pressure to equilibrate before oxygenation, ventilator parameters are often
measurement and thus provide, according to manipulated and the range of measured
some critical care professionals, more spirometry values is wide.
accurate values.
The following are some typical values or a
Typical values vary widely depending on the typical range of values for an adult patient.
patient’s condition. In anesthesia, where

Anesthesia Critical Care

TVexp 7 - 10 ml/kg 5 - 10 ml/kg
RR 8 - 12/min 8 - 12/min
I:E 1:2 2:1 - 1:4
Ppeak 15 cmH2O < 30 cmH2O
Pplat 12 cmH2O < 23 cmH2O
PEEPe 0-5 cmH2O 3 -10 cm H2O
PEEPi 0 cmH2O 0 - 6 cmH2O
Compl 35-60 ml/cmH2O 20 - 40 ml/cmH2O
Raw 10 cmH2O/l/s 5 - 15 cmH2O/l/s

60 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Graphical Information The Pressure Curve
Curves and loops appear on screen com- The pressure curve is a useful tool for
bined with the numerical quantitative tracking the characteristics of the delivery of
values. gas from the ventilator and the effect this
delivery has on airway pressures. A pressure
measurement is transcribed into a curve,
which has, in almost all cases, 3 characteris-
tic parts:

cm H2O

20 1

5 4
3 5

(1) The ventilator delivers a breath to the (3) When the ventilator cycles into expiration
patient by exerting a positive pressure. we see the pressure drop back to baseline.
Throughout this part of the inspiratory During this phase the lungs return to their
phase the pressure at the airway is deflated state. The pressure in the lungs
increasing until Ppeak has been would fall back to 0 or atmospheric pres-
reached. sure unless PEEP is applied.
(2) If an inspiratory pause is applied, there (4) In addition to the 3 phases we can also see
is a period after Ppeak where there is no the total area under this curve, known as
gas flow. This remains a part of the the mean airway pressure or Pmean.
inspiratory phase and is known as (5) With the application of PEEP we see that
Pplat. The pressure drop is due to gas the overall shape of the pressure curve is
distribution within the lungs. the same as that of the curve without PEEP.

The Flow Curve A B C

The flow curve and the pressure curve are cm H2O
2
closely related. This is because changes in 1 2 3 1
3
the characteristics of the delivered breath or 4 4
p
changes in patient lung mechanics can
induce changes in both pressure and flow
curves. Like the pressure curve, the flow l/m
3 3
curve can be divided into four distinctive
4
parts: o
2 4 2
V

1 1

A = inspiration time
B = pause time
C = expiratory time

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 61
(1)During inspiration, flow is either constant (3) Expiration begins with rapid emptying of
or decelerating until the preset volume the lungs due to the elastic forces of the
has been delivered (volume controlled lung/thoracic system. The flow gradually
ventilation) or the preset pressure/time slows down as the lungs empty and as
has been achieved (pressure controlled areas of the lungs with higher resistance
ventilation). or damage begin to empty. The flow
(2) An inspiratory pause is shown as a returns to zero at the end of the expira-
period of no flow on the flow curve. tory phase. This corresponds with airway
pressure returning to baseline (4).

Loops
Flow and pressure curves show these Pressure/Volume Loop
parameters over time in successive breath- From a pressure/volume loop, four phases
ing cycles. The graphical loops displayed by of ventilation can be seen as follows:
Patient Spirometry also show pressure and
flow but in relation to volume, not time.
Basically, the loops provide almost all the
information discussed above and an experi-
enced clinician is able to see at a glance the
status of the patient’s lung mechanics.

Spontaneous breath Controlled breath Controlled breath with PEEP

Vol
Vol Vol

3.

4.

2.

Paw 1. Paw 5. PEEP Paw

1) Beginning of Inspiration: volume is lower 4) Expiration: both pressure and volume

at this point, although pressure increases decrease as lungs deflate.
rapidly since the resistance of ventilator 5) If PEEP is applied the lungs return to a
tubing and the endotracheal tube as well baseline pressure which is above atmos-
as the surface tension of the alveoli must pheric.
be overcome before flow can start.
2) Inspiration: gas flows more freely into the Since the loop shows the relationship
lungs, there are larger volume changes for between pressure and volume, the slope
lower pressure changes. (angle) of the loop is an indicator of compli-
3) Pause: pressure decreases into a plateau ance.
while gas diffuses into the alveoli.

62 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Flow/Volume Loop
The flow/volume loop provides a clear view
of the flow relating to volume during inspira-
tion and expiration:

o o
V V
l/min 2. l/min
3.

V V
ml ml
1a
1b
1a constant flow
1b decelerating flow

1) Inspiratory phase: gas flows from the curve during expiration will vary
ventilator to the lungs. At this point the according to the presence or absence of
way in which the ventilator delivers the disease states, for example increased
flow will be distinguishable. airway resistance.
2) Expiratory phase: during expiration flow 3) If air is trapped in the lungs (PEEPi),
depends on patient airway & lung charac- expiratory flow will not reach the base-
teristics. Thus, the shape of a flow volume line.

Conclusion
Patient Spirometry is an informative tool associated with ventilation in the operating
that works hand in hand with the clinician room and critical care unit. It provides
in order to monitor ventilation in anesthesia graphical and quantitative information in
and critical care. When used correctly it the form of loops and curves and digit fields
allows the clinician to optimize ventilation that are integrated with other monitored
and avoid and/or treat possible hazards parameters on a single monitor screen.

Tasks 9.1 Ventilation, Patient Spirometry

Q1. What can patient spirometry assist with?

Q2. In what form can the information be delivered?

Q3. What is meant by the folloving abbreviations I:E, Ppeak, PEEP, Compl and Raw?

Q4. While investigating the pressure/volume loop at the beginning of inspiration, we

can notice that although pressure increases rapidly, volume is lower. Why?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 63
9.2 Patient Oxygen
A continuous, adequate supply of oxygen is the ventilator and the patient airway, the
necessary to sustain life: the oxygen reserves FiO2 is actually inhaled by the patient. But
of the body are small. Thus cutting or tubes, hoses and connections have been
impairing O2 supply will rapidly cause known to leak and the standard FiO2 meas-
irreparable damage. Some tissues can do urement offers no control over breathing
without oxygen for hours, but the brain may system integrity. In a breathing system with
be permanently damaged after a few min- low fresh gas flows, it is all the more impor-
utes without O2. As mentioned earlier, the tant to measure O2 at the airway.
whole delivery process of oxygen from the
lungs to the organs and tissues has to be in The Patient Oxygen measurement not only
balance to ensure proper oxidation at the offers actual inhaled oxygen (FiO2) values at
cell level. Corrective actions for inadequate the patient’s airway, but is also able to
oxygen supply at tissue level, hypoxia, may monitor the exhaled values, breath by
differ depending on whether the primary breath. This enables control of both the
cause for hypoxia is in ventilation, circula- patient’s lungs and the breathing circuit
tion or metabolism. To put it simply: how do (ventilator and connections), thus exceeding
you know how much oxygen your patient is the minimal standard requirements and
inhaling and exhaling unless you measure it? adding to patient safety.

The standard oxygen monitor in a ventilator The Datex-Ohmeda paramagnetic O2

can measure the oxygen content of the gas sensor is fast enough for breath-by-breath
mixture that leaves the ventilator, FiO2 measurement of O2 which allows a
(fraction of inspired oxygen). This is a simultaneous display of FiO2, EtO2 (end-
minimum requirement of modern interna- expiratory oxygen or end-tidal oxygen), I-EO2
tional standards. With high fresh gas flow, (the difference between inspiratory and
good luck and flawless connections between expiratory values) and the oxygram.

%
CO2 5 C ET
O
2
5.0 F I 0.0
RR 15/min
-0
%
O2 21
O ET
2
16 F I 21
16 F I - ET 5.0
%
Enf 5.0 E ET
2.0
n
f
2.3 F I 3.0
0 MAC 0.8

64 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 9.2 Patient Oxygen
Q1. How long can the brain be without oxygen before it may suffer permanent damage?

Q2. What is an inadequate O2 supply at tissue level called?

Q3. Why is it important to have a fast oxygen measurement method?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 65
 9.3 Inhalational Anesthetic Agents and N2O
Characteristics of Inhalational
Anesthetic Agents
Inhalational anesthetic agents are volatile volume. It causes dilation of coronary
(evaporate rapidly) administered by leading arterioles, and increases cerebral blood flow
the gas vapor from a vaporizer into the and intracranial pressure. It is quite a good
breathing circuit. The correct and safe muscle relaxant and strengthens the effects
administration of inhalational anesthetics of NMBAs30.
depends on how well the characteristics and
effects of each agent on the human body are Sevoflurane
known and how well their presence in the Sevoflurane came into clinical use in 1986 in
blood can be estimated. Japan. The most notable characteristic of
sevoflurane is its low solubility in blood,
Continuous monitoring of agent concentra- which makes it very quick in induction and
tion is needed to ensure that the patient gets recovery. Like other inhaled anesthetics,
the optimal dose of the agent. Anesthetic sevoflurane is a respiratory depressant.
agent concentrations are expressed in %. Muscle relaxation produced by sevoflurane
Monitoring can also show the wash in/out of is sufficient to permit endotracheal intuba-
the agent, thus making it easier to predict tion without NMBAs. It influences cerebral
the moment of emergence from anesthesia. circulation in much the same way as
isoflurane.
Halothane
Halothane was brought into clinical use in Desflurane
1956. It does not irritate mucous membranes. Desflurane was launched in the USA in the
It is a bronchodilator and therefore very early 90s. The solubility of desflurane in
good for asthma patients. It lowers the blood blood is low, which indicates that uptake
pressure, stroke volume and minute volume and elimination are especially rapid. It
of the heart, but it may cause arrhythmias irritates the airway and is not commonly
and/or increased intracranial pressure. used for induction. It has a boiling point of
It is metabolized to a large extent in the liver 23oC. In this respect it differs from other
(12 - 20 %), and might be hepatotoxic. It is inhaled anesthetics, which boil at higher
therefore not recommended to anesthetize temperatures, and it cannot be delivered
the same patient with halothane more than using standard vaporizers.
once within any given 1 - 2 month period.
Nitrous Oxide (N2O)
Enflurane
Nitrous oxide is also known as “laughing
Enflurane was launched in 1973. It does not
gas”. It causes light hypnosis, amnesia and
irritate the mucous membranes and is a
analgesia when administered in 30 - 70 %
bronchodilator. It may lower blood pressure.
inspiratory concentrations. It does not
When the concentration in the brain in-
produce an anesthetic state alone and
creases in the presence of hyperventilation,
therefore is usually used together with other
enflurane may cause convulsions, so it is not
anesthetic agents (either inhalational or
recommended for epileptic patients.
intravenous). It also reduces the dose of the
other anesthetic agents used to produce the
Isoflurane
same degree of anesthesia. N2O does not
Isoflurane lowers the respiration rate, tidal
irritate when inhaled. Like other
volume and blood pressure. It also increases
30
NMBA = anesthetics, N2O also depresses the heart.
neuromuscular blocking the heart rate and decreases the stroke
agent

66 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
MAC = Minimum Alveolar
Concentration
MAC = Minimum Alveolar Concentration 1.3 - 1.6 MAC prevents movement in nearly
equalizes the differences in the strength of all patients.
different anesthetic agents: 0.75 % of haloth-
ane or 6.0 % of desflurane are needed to The MAC concentration is influenced by age
make 50 % of the patients non-responsive to and some other factors that need to be taken
a standard skin incision. Clinically a MAC into account in the planning phase of
concentration greater than 1.0 is necessary, anesthesia.
because the other 50 % of the patients would
still react. Administration of approximately

Halothane Enflurane Isoflurane Sevoflurane Desflurane N2O

MAC (vol-%) 0.75 1.68 1.15 2.0 6.0 104*
* Theoretical value

Agent Identification
Identification of volatile agents helps to identifies it automatically at the moment of
detect misfilled vaporizers, vaporizer con- detection.
tamination and situations in which two
anesthetic agents are present at the same Measurement Principles
time. It also eases the daily routine in the
Anesthetic agents are measured by IR
operating room. It is not necessary to manu-
(Infrared) spectrometry.
ally select the agent because the monitor

%
CO2 5 C ET
O
2
5.0 F I 0.0
RR 15/min
-0
%
O2 21
O ET
2
16 F I 21
16 F I - ET 5.0
%
Enf 5.0 E ET
2.0
n
f
2.3 F I 3.0
0 MAC 0.8

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 67
Tasks 9.3 Inhalational Anesthetic Agents and N2O
Q1. Which one of the anesthetic agents mentioned is recommended for asthma patients and why?

Q2. What is another name for nitrous oxide?

Q3. What is the most important characteristic of sevoflurane and how does that influence the
anesthetic process?

Q4. What does MAC stand for?

Q5. Why is it important to have agent identification?

68 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
9.4 Electrocardiogram
ECG measurement
The heart is an electrical field in which 1) Direction
currents flow. The electrical activity of the The electrical impulses that are going
heart can be detected by placing electrodes towards the seeing electrode will cause a
on the skin. A lead is composed of two positive (upward) reflection on the ECG
electrodes of opposite polarity (bipolar) or waveform and those going away from the
one electrode and a reference point (unipolar). seeing electrode, a negative (downward)
reflection.
The electrocardiograph measures and
records the electrical impulses when they 2) Strength, Measured in Millivolts
are conducted through the different parts of The stronger the electrical impulse, the
the heart. The electrical signal generated by greater the reflection on the electrocardio-
the heart is very weak (from 0.5 to 2 mV) at the gram.
skin surface. Therefore optimum skin
preparation is important to avoid further 3) Duration
weakening and artifacts of the signal at the The ECG recordings are made over time: the
skin-electrode interface. longer the electrical activity continues, the
longer the reflection will be on the wave-
At least two electrodes are needed to detect form.
an ECG, and a third electrode serves as a
reference to reduce electrical interference. Leads
By placing the electrodes in different loca-
There are up to 12 leads in the standard
tions, the clinician can monitor different
ECG: 3 bipolar (I, II, III), and 9 unipolar
“views”, called leads, of the heart’s electrical
(aVR, aVL, aVF, V1...V6) leads giving infor-
activity.
mation about current flow in the different
parts of the heart. For HR monitoring
The measurement is done from negative
purposes only one lead, normally lead II, is
electrode to positive electrode. The positive
enough. For arrhythmia and ischemia
electrode is like a “seeing” electrode. The
monitoring more leads are used to provide
ECG basically measures three dimensions of
more viewing angles.
electrical activity:

R/RA right arm

L/LA left arm
RR L
F/LL left leg
N/RL right leg

C1/V1/C6/V6
1 2
3
4
C 5
6

N F

Limb leads Precordial leads

Electrode Placement
Up to 10 different locations for the ECG electrodes have been standardized to provide optimal
viewing angles.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 69
Normal
Electrocardiogram
The normal ECG signal consists of a series
of positive and negative deflections called
P, Q, R, S and T waves.

- +
1) The P wave is inscribed in lead II when
the sinus impulse activates the right
P atrium. Normal duration of the P wave is
no greater than 0.11 sec. and not taller
than 0.3 mV.

- +
2) During PR segment the His-bundle is
activated. The normal PR interval falls
P between 120 and 210 milliseconds.

- +
3) When the interventricular septum is
activated from left to right the Q wave is
P recorded in the ECG.

- +
4) A tall positive spike (R wave) is recorded
R
in the ECG when the two ventricles are
P activated. The QRS complex created by
the impulse moving through both ventri-
Q cles is normally 50 to 100 milliseconds in
duration.
- +
5) Electrical currents generated during
R
repolarization of the ventricles are re-
T flected in the flat portion following the
P
QRS complex: the ST segment and T wave
Q S following it. The point where QRS ends
and the ST segment begins is called the
J point.

70 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Ischemia monitoring Arrhythmia Monitoring
The ST segment is of particular interest to Arrhythmia monitoring consists of detecting
the clinician. Normally the ST segment is life- threatening situations, as well as
flat. An elevation above the base line of more analyzing the ECG for abnormal rhythms.
than 0.1 - 0.2 mV or a depression of more There are three life-threatening arrhythmias
than 0.1 mV is highly suggestive of ischemia. where the chaotic electrical activity in the
To be able to localize the ischemic area of heart does not result in mechanical pumping
the heart, multilead monitoring is required. of the blood, (asystole, ventricular fibrilla-
The 5-lead system permits recording of all tion, and ventricular tachycardia). It is
the limb leads (I, II, III, aVR, aVL, aVF) and important to monitor less dangerous
one precordial lead (V) at once. The 12-lead arrhythmia as well because there is a risk of
system adds the possibility to record all the deterioration of the rhythm to a letthal level.
precordial leads (V1 ... V6) at once.

Asystole

Ventricular fibrillation

Ventricular tachycardia

Tasks 9.4 Electrocardiogram

Q1. What does ECG stand for and what does it measure?

Q2. What can be found in a normal ECG signal?

Q3. Name the three dimensions of electrical activity measured by ECG.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 71
9.5 Cardiac Output

C.O. = SV x HR
where
Rate/min SV = stroke volume, ml/beat
HR = heart rate, beats/min.

Cardiac output was defined earlier as the these components, e.g. temperature, venous
amount of blood pumped by the heart in one return, blood volume.
minute (l/min):
Together with pulmonary capillary wedge
C.O. = SV x HR pressure measurement (PCWP, page 76),
cardiac output assists in evaluating left
Thus changes in cardiac output reflect ventricular function. The normal value for
changes in the factors that affect either of C.O. is 3-7 l/min. and depends on body size.

The Thermodilution Method

A known amount of solution with a known pulmonary artery. The temperature is
temperature (significantly lower than body measured downstream in the pulmonary
temperature) is injected into the right artery and plotted over time. Cardiac output
atrium. This cool solution cools down the is calculated from the following equation:
blood ejected from the heart into the

temperature °C

-1.0

C.O. = VI x (TB-TI) / A x K, where

VI = volume of injectate -0.5

TB = temperature of blood
TI = temperature of injectate A
A = area under temperature curve 0
K = computation constant, catheter specific time

Thus it is important to know VI, TB and TI and for constant temperatures and volume
exactly, because inaccurate values will cause of injectate:
an error in the cardiac output value. Area A - the bigger the area and thus the
is measured by the monitor. bigger the temperature change in the
pulmonary artery, the smaller the
From the equation we can see that for cardiac output.
a constant cardiac output:
- the bigger the volume, The measurement concept is easily under-
the bigger the area stood by analogy: if we pour the same
- the colder the injectate temperature, amount of cold milk into a small cup of hot
the bigger the area coffee and into a big cup of hot coffee the
small cup will cool down more.

72 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 9.5 Cardiac Output
Q1. What is C.O. and what is the “normal” value for it?

Q2. What can C.O. assist in evaluating?

Q3. What is the working principle of the thermodilution method?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 73
9.6 Blood Pressures
Pressure and Resistance
The pressure exerted by blood against blood. The left ventricle has to create a lot of
the walls of the blood vessels is called pressure to overcome the high resistance of
blood pressure. It is expressed in mmHg. the long systemic circulation. The right
Resistance to flow depends on the length ventricle only needs to pump blood through
and the diameter of the ‘‘tubing’’ (the arter- the pulmonary circulation which has a low
ies and veins), and the viscosity (thickness) resistance to blood flow and thus the
of the blood: pressure needed is much smaller.

The heart pumps blood through the circula-

tory system to maintain an adequate flow of

Change Resistance
Length
Diameter
Viscosity

DIFFERENT PRESSURES

Arterial vs. Venous Pressure

The higher the resistance of the tubing,
the more the pressure will drop between
two given points along the route. Thus,
blood pressure on the arterial side of
circulation is higher than on the venous
side. Also, the absolute pressure of pulmonary
systemic arteries is several times greater circulation
than that of the pulmonary arteries.

systemic
circulation

coronary
circulation

74 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Systolic, Diastolic and Mean
Pressures
If the heart were a linear pump, delivering a The heart's contraction is equivalent to a
steady and continuous flow of blood into situation where the volume of the tubing
circulation, then the pressure exerted by the decreases while the volume of fluid in the
flowing blood against the walls of the blood system remains the same. Thus pressure
vessels would be stable (constant) regardless increases. In physiology the highest pressure
of its absolute value. However, the heart is called systolic pressure and it closely
delivers blood in “boluses”, a certain volume equals the highest pressure generated by the
with each contraction and thus creates left ventricle at the end of cardiac systole.
pressure pulses. The relaxing heart increases its volume and
thus the volume of the tubing increases.
mmHg
Thus pressure decreases. As the heart
120 relaxes, the aortic valve closes and the
systolic
pressure starts to decline in the arterial tree.
The lowest pressure during this phase is
60 called the diastolic blood pressure.
diastolic

The mean arterial pressure (MAP) is the

0
average pressure in the artery over time.

THE INFORMATION VALUE OF

DIFFERENT PRESSURES
High pressure = increased flow or fluid circulation. A persistently elevated systolic
volume or decreased diameter. pressure indicates increased cardiac output
or decreased distensibility of the arteries.
Low pressure = decreased flow or fluid
volume, increased diameter or leakage.
The diastolic pressure which remains in the
artery during the resting phase of the heart
Systolic and Diastolic Arterial reflects the peripheral resistance. Myocar-
Pressure (120/80 mmHg) dial perfusion depends on the diastolic
The systolic pressure generated by the blood pressure as most perfusion occurs
contracting heart reflects the oxygen de- during diastole. Too low a diastolic pressure
mand of the heart itself: the stronger the endangers oxygen delivery to the heart
contraction (and hence the pressure) the muscle while too high a diastolic pressure
more oxygen is consumed. It is important indicates a constriction in the peripheral
that the systolic pressure is high enough to circulation.
overcome the vascular resistance of systemic

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 75
Mean Arterial Pressure (MAP), Pulmonary Artery Pressure
(60 - 90 mmHg) (PAP), (30/15 mmHg)
Mean arterial pressure reflects the driving The pulmonary artery pressure is the pulmo-
pressure pushing blood into an organ. nary equivalent of systemic arterial pressure
When measured continuously, it normally and gives information on the pulmonary
fluctuates less than systolic pressure. circulation. Like arterial blood pressure, it is
pulsatile. The systolic value, PASP, reflects
Systemic arterial blood pressure combined the pressure generated by the contraction of
with heart rate is used to assess the the right ventricle and the diastolic value,
adequacy of tissue perfusion. PADP, reflects the resistance of the pulmo-
nary circulation.
Central Venous Pressure (CVP),
(Mean, 1 - 10 mmHg) PCWP, Pulmonary Capillary
CVP is measured through a catheter Wedge Pressure
inserted into the superior vena cava. It (Mean, 5-15 mmHg)
closely reflects the pressure in the right
Left Ventricular End-Diastolic Pressure
atrium and depends on several factors; the
(LVEDP), (Mean, 5-15 mmHg)
volume status (hypovolemia /hypervolemia),
The PCWP is measured from the right side
the right ventricle performance, and
of the heart, from the pulmonary artery.
resistance of pulmonary circulation. It also
If the pulmonary artery is occluded (closed,
reflects the right ventricle’s ability to pump
blocked) with a balloon, and the pressure
out the blood that returns from systemic
beyond the balloon is measured while the
circulation, to pulmonary circulation. It
mitral valve at the left side of the heart is
often corresponds to that of the left ventri-
open (i.e. at the end of the left ventricular
cle. It is sometimes referred to as right
diastole), the pressure in the pulmonary
atrial pressure (RAP) which is close to the
artery reflects the pressure in the left atrium
measurement site. Measuring CVP without
and in the left ventricle and thus indicates
matching it with other information can be
the left ventricular preload. This is called
misleading. PCWP or PaOP = pulmonary artery
occlusion pressure.

76 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
HOW IS BLOOD PRESSURE
MEASURED?

Systemic Arterial Blood

Pressure
Whatever the setup for systemic blood open the artery. When the blood rushes
pressure measurement, one needs to remem- through the small opening in the artery it
ber that pressure is affected by gravity: the flows turbulently and creates distinct pres-
pressure in any vessel above heart level is sure waves. These can be listened to by a
lower than at heart level. The pressure in stethoscope or they can be measured with a
any vessel below heart level is higher than at pressure transducer. The systolic reading is
heart level. Therefore the pressure measure- obtained at this cuff pressure.
ment site should usually be at heart level.
Further deflation of the cuff will eventually
Non-Invasive Blood Pressure fully open the artery and the blood flow will
become laminar. The point where the
(NIBP) distinct sounds - the Korotkoff sounds - will
In the non-invasive method an artery, disappear indicates a fully open artery. The
usually in the arm, is occluded by inflating diastolic reading is obtained at this cuff
(pumping air into) a cuff that has been pressure.
applied around the upper arm. When the
cuff is then gradually deflated, the pressure Non-invasive blood pressure monitoring is
in the artery becomes equal to the cuff best suited to low and medium-risk situa-
pressure and with further deflation is able to tions as it is not continuous.

120

100
mmHg
80

60

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 77
Invasive Arterial Blood Pressure
The setup for invasive blood pressure
mmHg
measurement includes inserting a catheter
120
filled with heparinised saline (physiological systolic
salt solution with anti-clotting agent) into an
appropriate artery, e.g. wrist or arm. The
60
catheter is coupled via a fluid-filled tube to a diastolic
pressure transducer outside the body.
Because of the relative incompressibility of 0
water, the fluid in the tube will transmit the
pressure from the catheter tip to the trans- Arterial blood pressure waveform
ducer.

Monitoring invasive blood pressure offers

continuous, beat-to-beat information on the
patient’s cardiovascular status. It has be-
come a widely used method in medium- to
high-risk situations.

Other Invasive Pressures

Other invasive pressures - CVP, PAP and
PCWP - use the same principle as invasive RAP RVP PA PCWP
arterial blood pressure but the measurement 40
PA mmHg
sites are in an extremely delicate area, the
20
heart and the pulmonary arteries. A catheter RA
may have several lumens for pressure
measurement. 0
RV

At the tip of the catheter there is an inflat-

Other invasive blood pressures
able balloon which serves two purposes:

• When the catheter is inserted - most

commonly from the jugular vein in the
neck, and pushed along towards the
heart, inflating the balloon in the vena
cava will cause the flowing blood to pull
the balloon into the right atrium, then to
the right ventricle and eventually into the
pulmonary artery.

• When in the pulmonary artery, inflating

the balloon will occlude the artery,
stopping the flow in it. Thus the pressure
at the artery catheter tip equals that on
the venous side of the lungs and reflects
that on the left side of the heart.

Continuous monitoring of the pressures

along the route of the catheter tip will help
to identify the location of the tip without
having to resort to X-rays.

78 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 9.6 Blood Pressures
Q1. What is the unit of measurement of blood pressure?

Q2. What is the

a) highest
b) lowest blood pressure called ?

Q3. What does MAP stand for?

Q4. What does CVP stand for and what does it indicate?

Q5. What is the PAP?

Q6. What is PCWP and what does it give information about?

Q7. To which type of monitoring is non-invasive blood pressure measurement suited and
why?

9.7 Tissue Oxygenation - SpO2

While airway oxygen monitoring gives
is needed to estimate the oxygen saturation
valuable information on the first stages of
of arterial blood, SaO2: i.e. the ratio of
the “vital logistics” process, there is also an
oxygen carrying hemoglobin, O2Hb, to the
obvious need to estimate the efficiency of
total hemoglobin:
later steps in the process of circulation and
oxygenation. As we remember, properly O2Hb
managed ventilation does not guarantee an SaO2 =
O2Hb+Hb+DysHb
adequate oxygen supply to the tissues.

Thus a simple, cost-efficient, non-invasive The estimate of SaO2 obtained by a non-

and reasonably accurate and rapid method invasive optical method is called SpO2.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 79
The Principle of SpO2
Measurement
Pulse(wave) oximetry, the method currently blood we can relate the changes in this
in wide use to estimate SaO2 and also a difference to the changing diameter of the
minimum requirement of international artery as blood pulsates through it. We now
standards is based on the following factors: have pulse-wave oximetry: the darker the
pulsating fraction, the less oxygen the blood
1) arterial blood is bright red whereas carries. The practical measurement is
venous blood is darker, (they absorb light performed by sending a beam of light
at different wavelengths). through the finger (or toe or ear etc.) and
2) arteries pulsate with the rhythm of the measuring the amount of light that passes
heart as a “bolus” of blood is pressed through. The wavelengths of the light
down with each contraction. correspond with the characteristics of the
3) peripheral veins do not usually pulsate. oxygenated and deoxygenated blood. The
amount of transmitted light is proportional
By continuously measuring the color to the amounts of oxygenated hemoglobin
difference between the arterial and venous vs. deoxygenated hemoglobin.

Systole

Diastole

Intensity of
transmitted I max (DC-component)
light I max
AC-component
I min

Variable absorption
Transmitted
due to pulse added
light
volume of arterial
blood

Arterial blood

Venous blood

Tissue

Time
No pulsation Pulsatile blood

Incident light

80 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Important SpO2 Parameters can be detected. Blood, however, also
contains other hemoglobin fractions
Through SpO2 we can get both the numeri-
(DysHb), although in small, usually constant
cal estimation of arterial oxygen saturation,
quantities. The carboxyhemoglobin (COHb)
(normal range 97 - 100 %), and the plethys-
fraction is normally small, but may be highly
mographic waveform indicating pulsating
elevated in smoke inhalation patients (in-
blood volume in the peripherial artery.
cluding heavy smokers). The SpO2 measure-
ment interprets the presence of COHb as
Limitations of SpO2 O2Hb and thus overestimates oxygen satura-
An adequate degree of arterial oxygen tion.
saturation guarantees neither the release of
oxygen to the tissues nor the ability of the
tissues to utilize it. Thus, an awareness of
External Interference
Motion artefacts, electrosurgery and pulsat-
this serves to remind us that SpO2 values are
ing light may also interfere with SpO2
only an estimation of the degree of tissue
measurement. Hence, the integrity of the
oxygenation.
pulse waveform is also a necessary indicator
of the absence of external interference.
Limitations of Method Despite its limitations pulse oximetry has
The basic limitation of the SpO2 method is proven an invaluable help in assessing the
that, if blood circulation to the periphery is patient’s oxygenation status in various
limited (poor perfusion), there is no detect- environments: operating room, critical care
able pulse and consequently no signal. unit, recovery and the ward. It is successful
Another limitation arises because only two because it meets the requirements of sim-
wavelengths are being used in the measure- plicity, non-invasiveness, continuity, trans-
ment. Thus only two forms of hemoglobin portability and reasonable accuracy.

Pleth 5 S %
p
0
97
2

Tasks 9.7 Tissue Oxygenation – SpO2

Q1. What does SaO2 measure?

Q2. What is SpO2 an estimation of and in which forms does it come?

Q3. What factors is the pulse oximetry measurement based on?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 81
 9.8 Gas Exchange
Pulmonary gas exchange measurement, also stand-alone monitors or incorporated in
known as indirect calorimetry, allows critical care ventilators. Some of them are
continuous and non-invasive measurement designed specifically for exercise testing.
.
of oxygen consumption (VO2) and carbon
. .
dioxide production (VCO2), and calculation Carbon dioxide production (VCO2) equals
of respiratory quotient (RQ) and energy the amount of CO2 expired minus the
expenditure (EE). The clinical applications amount of CO2 inspired (which usually is
range from assessment of energy require- zero):
ments and response to nutrition, to compre- .
hensive analysis of ventilation and oxygen VCO2 = MVexp x FeCO2 - MVinsp x FiCO2
transport in patients with complex cardio-
In the same way, the oxygen consumption
vascular problems. .
(VO2) equals the amount of O2 inspired
minus O2 expired:
Calorimetry means measurement of energy
.
expenditure. Heat loss from the body, which VO2 = MVinsp x FiO2 - MVexp x FeO2
indicates the energy expenditure, can be
directly measured by whole-body or direct In order to obtain sufficient accuracy for
calorimetry. The subject is placed in a clinical purposes, both gas concentrations
sealed, insulated, box-like chamber, and the and related volumes have to be determined
heat produced is removed by water circulat- with a high degree of precision. No known
ing through the coils inside the chamber. flow sensor has turned out to be able to
Direct calorimetry is a cumbersome and define both expired and inspired volumes
slow process and hence is seldom used. accurately enough. The only solution is to
measure only either expired or inspired
Indirect calorimetry is based on the meas- volume and derive the other with the so-
urement of pulmonary gas exchange, which called Haldane transformation. This means
in steady state corresponds to the release of taking advantage of the fact that the body is
energy from the body. Every time the neither consuming nor producing nitrogen.
homeostasis of a patient is changed, the Drawbacks are that the measurement
steady-state condition is disrupted, and a becomes impossible at O2 levels approaching
certain period of time has to pass before a
100% and in gas mixtures where N2 is
new steady-state is re-established. This is
replaced by N2O, as happens quite often
very important when the measurement is
during anesthesia.
made over a short period, but in continuous
measurement it is possible to obtain average . .
When VO2 and VCO2 are measured, it is
results over longer periods and then the
possible to calculate energy expenditure
effects of a varying steady-state are elimi-
(EE). The equation used to calculate EE is:
nated.

EE (kcal/24h) =
. .
Measurement principle 5.5 VO2 (ml/min) + 1.76 VCO2 (ml/min) - 2UN (g/24h)
Traditionally, indirect calorimetry has been
performed by collecting expired air into a Since the significance of UN31 in the equa-
Douglas bag during a time interval and then tion is very small, it is usually assumed to be
analyzing the gas concentrations and vol- constant (13 g/24h for adults, 0 g/24h for
31
ume. Newer methods use gas sensors and children). If UN is measured, a complete set
UN =
urinary nitrogen flow/volume transducers, measuring O2 of equations based on calorimetric values
32
uptake and CO2 continuously and automati- for each substrate32 can be written and solved
substrate=
a substance upon which an cally. Most of the existing devices are either to result in separate substrate oxidation
enzyme acts

82 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
rates for carbohydrates, fats and proteins. In a wider perspective, the monitoring of
A rough idea about which substrate is oxygen consumption has additional applica-
mainly utilized can be obtained from the tions in the assessment of the overall oxy-
respiratory quotient (RQ), which is defined genation status of the patient. Measurement
. . .
as RQ = VCO2 / VO2. of VO2 directly by the gas exchange method
offers some obvious advantages compared
Clinical Applications to the traditional Fick method, which
.
calculates VO2 based on measured C.O.,
Indirect calorimetry has a wide range of - . The Fick method is prone to
SaO2 and SvO
applications both in clinical practice and 2
larger variations, requires blood gas analysis,
research. The main application aims at
is intermittent and it does not take into
optimizing nutrition so that both malnutri- .
account the pulmonary VO2.
tion and overfeeding can be prevented. In
malnourished patients the respiratory
In anesthesia, promising application areas
strength decreases, leading to difficulties in
are all major surgeries causing major blood
weaning the patient from the ventilator.
loss or volume changes, where continuous
During overfeeding the body increases CO2 .
VO2 could be used to estimate adequacy of
production, leading to increased respiratory
circulating blood volume or the effects of
demand. The patient groups whose caloric
therapeutic interventions. In major organ
needs differ most from predictions include
transplantation it is valuable to follow by
patients with burns, severe infections and .
VO2 measurement the process of the new
neurological trauma or disorders.
organ becoming a part of circulation.

Tasks 9.8 Gas Exchange

Q1. Why is indirect calorimetry performed?

Q2. Nowadays, how is indirect calorimetry performed?

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 83
9.9 Mixed Venous Oxygen Saturation
We have covered the estimation of oxygen ‘‘Mixed venous’’ indicates that blood from all
saturation of arterial blood by SpO2. This veins coming from the different organs, as well
reflects the oxygen delivery to the organs as blood from the superior and inferior vena
and tissues and in low- to medium-risk cava, has been mixed. SvO2 thus represents a
situations is sufficient. With critically ill global measure of the total body system. The
patients, intermittent cardiac output and normal range for SvO2 is 60 - 80 %.
arterial blood gas measurements provide the
clinician with a fuller picture of oxygen SvO2 can be continuously monitored with a
supply, but there is still a need to relate the special catheter which contains fiber optic
oxygen supply to oxygen demand and sensors. The measurement principle is the
consumption. same as with pulse oximetry, SpO2, except
that while SpO2 is based on absorption of
Mixed venous oxygen saturation, SvO2, is light, SvO2 is based on reflectance of light.
the difference between arterial oxygen
saturation and body oxygen consumption The same limitations due to
and is measured in the pulmonary artery. carboxyhemoglobin apply.

pulmonary circulation

pulmonary SaO2 95-100 %

artery +
catheter PAO2 Hb 120-180 g/l

alveolus

right side left side of

of heart AaDO2 the heart
SvO2 10-15 mmHg
60-80 %

systemic circulation
C.O.
3-7 l/min

Tasks 9.9 Mixed Venous Oxygen Saturation

Q1. What is meant by mixed venous oxygen saturation SvO2 and where is it measured?

Q2. What is the normal range for SvO2?

84 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
9.10 Carbon Dioxide
In the last decade CO2 monitoring in the An analysis and understanding of the CO2
airway has become standard in anesthesia waveform shape and end-tidal CO2 measure-
and is finding its way to critical care areas as ment are very important for the early diagno-
well. It can provide valuable information on sis of adverse events such as hypo-/hyperventi-
the patient’s ventilation, circulation and lation, esophageal intubation, circuit discon-
metabolism. nection or defective breathing systems.

%
CO2 5 C ET
O
2
5.0 F I 0.0
RR 15/min
-0
%
O2 21
O ET
2
16 F I 21
16 F I - ET 5.0
%
Enf 5.0 E ET
2.0
n
f
2.3 F I 3.0
0 MAC 0.8

The capnogram33 can be analyzed according

to different criteria:

Height: depends on the EtCO2

concentration (Normal range:
4.8 - 5.7% or kPa, 36 - 43 mmHg)
Baseline: normally should be at zero.
A higher value indicates
rebreathing of CO2.
Shape: there is only one normal shape
for the capnogram. Any change
in the shape should be investi-
gated.

33
Capno=
the presence of carbon
dioxide

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 85
 AB C D E D-E: When inspiration starts, the capnogram
rapidly falls towards the baseline.
End-Tidal CO2 (EtCO2) is a non-invasive,
breath-by-breath indicator of:
inhalation exhalation inhalation
• Metabolism: production of CO2
• Circulation: transport of CO2
• Ventilation: elimination of CO2
A-B: Inspiratory baseline with ending of
inspiration and beginning of expiration. It is a useful parameter for defining the
Elevations of the baseline indicate efficiency of mechanical ventilation, assess-
rebreathing of CO2 . ing adequacy of cardiac output and sudden
increase in metabolism. It may also assist in
B-C: Rapid increase of CO2 concentration as correctly positioning the endotracheal tube.
expiratory gas comes from anatomical dead
space and then from the alveoli. The shape Besides the numerical value of EtCO2, the
varies with the duration of expiration: the capnogram usually helps to determine the
less steep this part of the curve, the more actual reason for abnormal EtCO2 values.
prolonged the expiratory phase. This can be Therefore the EtCO2 value should always be
due to: evaluated with simultaneous analysis of the
• Kinked endotracheal tube capnogram.
• Obstruction in the airway
• Acute bronchospasm. Under normal circumstances EtCO2 closely
corresponds with the arterial partial
C-D: An alveolar plateau is reached when pressure of CO2, PaCO2. The normal physi-
the exhaled gas originates entirely from the ological difference between EtCO2 and
alveoli. The end-tidal CO2concentration is PaCO2 varies between 2 and 5 mmHg.
measured at the end of this plateau.
Factors that can change the shape of the
alveolar plateau include:
Measurement Technology
Datex-Ohmeda CO2 measurement is based
• Patient breathing against the on the infrared principle, which is fast and
ventilator allows breath-by-breath monitoring with
• Obstruction in the airway or display of the capnogram. The same infrared
increased airway resistance “bench” is also able to measure N2O and
• Mechanical irritation of the anesthetic agents.
abdominal area by the operating
surgeon.

Tasks 9.10 Carbon Dioxide

Q1. What is the CO2 waveform called ?

Q2. EtCO2 is a non-invasive breath-by-breath indicator of three functions. Name them.

Q3. Why is it advisable to analyze both the numerical and graphical information of EtCO2?

Q4. What is normoventilation?

86 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
9.11 Temperature
The balance between heat production and the naked surface, conduction to a colder
heat loss determines the body temperature. object and evaporation of water. Intravenous
Body heat is produced by metabolic pro- cold solutions also cool down the patient
cesses and muscular activity (including whose regulation feedback system is
shivering). It is lost mainly by radiation, anesthetized.
conduction and vaporization of sweat.
In cardiac surgery the patient’s temperature
Regulation of Body Temperature is lowered on purpose to decrease oxygen
consumption and to help protect the heart
The physiological regulation of body tem-
while it is not getting any blood flow.
perature takes place in the hypothalamus in
the brain. It acts like a thermostat by meas-
uring the temperature of the blood, receiving Hyperthermia During Anesthesia
information from the skin receptors and A rise in body temperature might be antici-
starting balancing mechanisms when pated in a patient already feverish with
necessary. Altered function or impairment of uncontrolled infection or in a hot and humid
the regulation mechanism, or inadequacy of environment. An uncommon, but potentially
the balancing mechanisms, leads to either fatal disease, malignant hyperthermia, is a
hyperthermia (too high temperature) or hypermetabolic crisis that can be triggered
hypothermia (too low temperature). by anesthetic drugs, namely commonly
inhaled anesthetics and succinylcholine.
Normal Temperature Values If not recognized and treated promptly,
malignant hyperthermia has a high mortality
Body temperature is normally maintained
rate. Early indications include increasing
within limits of +/- 2 centigrade despite large
EtCO2, followed by a rapid temperature
variations in ambient temperature. The
increase of as much as 1oC/5 minutes, unsta-
temperature is different at different sites in the
ble blood pressure, tachycardia (HR>100
body, being lowest on the skin of the extremi-
beats/min.) and arrhythmias.
ties and highest in the core of the body.
Normal values range from 32 centigrade on
the skin to around 38 centigrade in the core. Temperature Measurement Sites
The measurement(s) should be taken at
Body Temperature Regulation appropriate sites where there is least risk to
the patient and no obstacles to good thermal
During Anesthesia contact. During long periods of monitoring
The direct effects of anesthetics and NMBAs and with newborn babies, the possible
impair the physiological temperature regula- redistribution of heat can be detected by
tion mechanism. During general anesthesia, monitoring the differences between the
the hypothalamus is also anesthetized. temperatures of different sites.
Redistribution of heat from the core to the
extremities is often present. Consequently, Esophageal temperature reflects myocardial
many of the patients who have a normal or aortic temperature, but its accuracy may
temperature on arrival in the OR suffer from be affected by a surgical procedure. The
hypothermia after the operation. probe can be introduced either through the
mouth or the nose and pushed all the way
Hypothermia During Anesthesia down to the lower fourth of the esophagus.
Inadvertent hypothermia is often seen in
long operations and in newborn babies. The Skin temperature varies from site to site, the
mechanisms leading to it are radiation from most stable site being the armpit where the

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 87
temperature is somewhat lower than in Tympanic membrane (eardrum) temperature
the rectum or esophagus (around 36oC vs. reflects that of the carotid artery that
37.3oC). supplies blood to the brain and the middle ear.

Rectal temperature may also be monitored Pulmonary artery catheters include a

but local intestinal infections may cause temperature probe which enables continu-
deviation from core temperature. ous monitoring of blood temperature.

Tasks 9.11 Temperature

Q1. Which part of the brain regulates the body temperature?

Q2. Within which limits is body temperature normally maintained?

Q3. Name four areas where body temperature may be effectively measured.

9.12 Neuromuscular Transmission

If one is punched in the stomach, the blockers affect this transmission of the
abdominal muscles will contract as a protec- electrical impulse, and that is why monitor-
tive reflex. The same happens in abdominal ing of the blockage is performed by provid-
surgery during skin incision or handling of ing an external electrical impulse to a nerve
the gut. This may be prevented by using and observing or measuring how the muscle
large doses of central depressants such as responds to it. The smaller the response, the
halothane, but their undesirable side effects, more paralyzed the patient.
i.e. depression of the heart and the liver, call
for another approach to relaxation. Neuromuscular blocking agents abolish the
protective reflex by preventing normal
The patient is sometimes paralyzed by using transmission of impulse from the nerve to
neuromuscular blocking agents (NMBAs) to the muscle:
make surgery possible, or to facilitate
mechanical ventilation. Whenever neuro- The chemical transmitter between
muscular blockers are used, it is recom- the nerve and the muscle is acetyl-
mended that their effect is monitored. choline, which binds reversibly to the
receptors on the muscle side,
A muscle gets an order to contract as a producing depolarization and muscle
chemical message generated by an electrical contraction.
impulse from a nerve. The neuromuscular

88 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Neuromuscular blockers can be divided into given with short intervals, and the slope of
two groups on the basis of their action on the fade is related to the level of blockage.
the neuromuscular junction. The most common monitoring mode is
therefore to give four stimuli (Train of Four,
Depolarizing agents (succinylcholine) TOF), and then to measure the fade in the
rapidly block the effect of responses. Depolarizing drugs simply cause
acetylcholine by occupying the a reduction of amplitude in the response to
receptor sites for a short period, stimulation.
while non-depolarizing agents such
as vecuronium compete with acetyl- The effect of neuromuscular blockers is
choline for the receptor sites and terminated through metabolism. Restoration
produce a longer lasting paralysis. of normal muscle function (including
breathing) can be hastened by administering
It should be noted that the neuromuscular antidotes for non-depolarizing agents such
blockers do not cross the barrier between as neostigmine and atropine.
the blood and the brain and have no central
depressing effects. Thus a patient may feel The adequacy of neuromuscular blockade
pain or fear unless adequate analgesia and should always be monitored whenever
sedation is ensured. NMBAs are used. If neuromuscular blockade
(NMB) is incomplete, the relaxation it causes
The two types of neuromuscular blockers - is also dependent on e.g. depth and the
depolarizing and non-depolarizing - affect effect of surgical stimuli. The level of this
muscle response in different ways. The more relaxation can be measured by electro-myo-
commonly used non-depolarizing drugs graphy (EMG).
show a fade in the responses for stimuli

Stimulus

Depolarizing block TOF Count = 4

Fade TOF Count = 3

Non- Depolarizing
block

TOF% = 15
75
x 100% = 20 %

Tasks 9.12 Neuromuscular Transmission

Q1. What do neuromuscular blocking agents accomplish?

Q2. What are the two groups of neuromuscular blockers and how do their effects differ?

Q3. Give the methods of putting an end to the effect of neuromuscular blockers.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 89
 9.13 Electroencephalography

As described earlier, when neurons commu- tenth of the ECG amplitude. This obviously
nicate with each other, they send electrical puts some pressure on the measurement to
impulses. These impulses are very small, succeed in a noisy environment such as the
but when millions of neurons work together, OR or the ICU.
their activity can be recorded from the
surface of the body as a voltage, much To be able to measure such a small signal,
like in ECG. the first thing to ensure is that the contact
between the electrode and the skin is good.
Electroencephalography (EEG) measures the Often the skin is “prepped” which means
spontaneous electrical activity of the that grease and dead cells are removed from
cerebral cortex, i.e. the surface layer of the the skin surface so that the contact is better.
brain. In a healthy brain, this activity is quite Conductive gel or paste is also used to
similar in different regions of the brain. improve the contact.
The EEG has no constantly occurring
pattern like the QRS in ECG, but it can be When all the preparations are done, there is
described as a superposition of various a way to evaluate the contact by measuring
continuous wave patterns – it is actually the impedance34 between the electrode and
sometimes difficult to differentiate real brain the skin. For good results, impedance should
activity from random noise. not be higher than 5 kilo-ohms.

Measurement Principle Interpretation of EEG

The EEG is measured basically like an ECG: The EEG can be characterized by its
as a voltage difference between two elec- amplitude (strength) and, more importantly,
trodes. The amplitude of the EEG as re- by what frequencies it contains. The EEG
corded from the skull surface is usually in has traditionally been divided into four
the range of 100 microvolts (V), so about one frequency35 bands:

34
impedance =
resistance
to alternating current

35
frequency:
Hz (Herz) is the unit of
frequency =1/s

90 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
 Power • Delta from 0 to 4 Hz
• Theta from 4 to 7 Hz
• Alpha from 7 to 13 Hz
• Beta from 13 Hz up

Delta Theta Alpha Beta

4 7 13 40
Frequency / Hz

EEG changes form due to many factors. The Evoked Potentials

naturally occurring changes are due to
Where EEG represents the spontaneous
changes in state of consciousness: the fully
electrical activity, it is also possible to evoke
awake human being who is concentrating on
brain activity in certain areas of the brain by
a task has fast frequencies in the EEG,
stimulating the corresponding sensory
whereas someone asleep has slow delta
system. This creates Evoked Potentials (EPs)
waves in the EEG.
which are named according to the related
sensory system as:
During surgery, changes in EEG are most
often induced by anesthesia: as in natural
• AEP = Auditory Evoked Potentials
sleep, the deeper the anesthesia, the slower
• SSEP = SomatoSensory
the EEG. Unnecessarily deep anesthesia can
Evoked Potentials
even result in a flat EEG.
• VEP = Visual Evoked Potentials

Similar changes are also caused by inad-

equate cerebral oxygenation. If blood flow to Measurement Principle
the brain decreases or stops for some reason, Measurement of evoked potentials requires a
the consequence is a very rapid slowing of means of stimulation and recording. AEP
the EEG. stimulation means in practice delivering
clicks to the ear(s) through a headphone. For
A third factor slowing EEG is body tempera- SSEP, small electrical pulses are delivered to
ture. In cardiac surgery, the patient’s EEG is a peripheral nerve and for VEPs different
intentionally brought to an isoelectric, flat kinds of images or flashes are shown to the
state by cooling. This is done because when patient.
the EEG is flat, the brain also consumes very
little if any oxygen and therefore it is safe to The evoked potential signal is very small:
cut the circulation to the brain for a while. in the order of a microvolt. Since the sponta-
neous EEG is running constantly as well, the
One reason for admitting the patient to the signal is hidden under the EEG and there-
ICU is epileptic seizures, which show up as fore cannot be read directly from the EEG
large amplitude peaks or waves in the raw waveform. Fortunately, we know that the
EEG. Continuing seizures damage the brain, evoked potential always occurs right after
which is why they are suppressed with we have delivered a stimulus, whereas EEG
drugs. is not related to the stimulation. Therefore, if

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 91
 ms
1 2 5 10 20 50 100 200 500 1000

EEG signal with auditory stimulation, where The average AEP response.
the arrow is pointing.

we deliver some hundreds of clicks and sum In AEP, the first 10 ms comes from the brain
the resulting signal, the sum of the stem, the segment from 10 to 100 ms from
arbitrarily oscillating EEG signal is zero, the cortex, representing primary processing
whereas the EP is always the same and is of the sound. What comes after that, con-
amplified by the resulting signal. tinuing up to one second, represents higher
processing also done in the cortex.
The number of stimuli can range from
100 to some thousands depending on the The time it takes for a wave to occur after
situation and the amount of external noise, stimulation is called latency. When interpret-
how good the signal should be and how ing evoked potentials, both the latency and
much time is available. the amplitude of the waves are important.
Sometimes the mere existence or non-
Interpreting the EP existence of certain waves tells us much
about the functioning of a certain part of the
The different waves in the EP come from
nervous system.
different parts of the nervous pathway.

Tasks 9.13 Electroencephalography

Q1. What does EEG provide information about?

Q2. What is the maximum recommended level of impedance? And how can impedance be reduced?

Q3. What information is provided by changes in EEG?

Q4. Name the important factors in the interpretation of evoked potentials.

92 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
9.14 Gastric Tonometry
Gastric tonometry measures CO2 in the If we feel anxiety, are scared or some stimu-
stomach in the gastric mucosa. The param- lus in our surroundings changes very fast,
eter is called PgCO236 (previously known as the blood from our stomach is redistributed
PrCO2). This provides information on the to the vital organs. This is also the case in
adequacy of gastric perfusion. critical conditions, because the stomach is
not needed in such a situation so the blood is
Clinical Background transferred to organs that are essential for
survival, such as the brain, heart and mus-
The stomach is an interesting organ for
cles. Our prehistoric ancestors had this
measurement. It is the first organ to suffer
physiological response in threatening
from any changes in blood flow and the last
situations, and as genes change slowly we
to recover when the situation normalizes.
still react as they did. A healthy person can
Secondly it is quite easy to access it, and
experience this reaction many times per day
thirdly, stomach plays an important role in
and the blood returns back to the stomach
the development of dangerous diseases like
automatically when the threatening situa-
sepsis and MOF (Multiple Organ Failure).
tion is over.

Blood flow brings oxygen (O2) to the tissue

In a critically ill person, this redistribution
and removes carbon dioxide (CO2) from the
remains, increasing the risk of tissue dam-
tissue. So when the blood flow is not
age and organ disfunction.
adequate CO2 starts accumulating in the
stomach. This can be measured with gastric
tonometry.

hypovolemia
cardiac failure MOF

redistribution
of blood flow

hypoperfusion vicious
circle
PgCO2

tissue
damage

mucosal
disruption

sepsis
endotoxin and
bacteria
translocation cytokine
release

36
PgCO2 = gastric PCO2

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 93
The Measurement Principle
A special tonometry catheter is inserted into The monitor infuses air into the catheter
the stomach. The catheter consists of a balloon and draws a sample every 10 min-
gas-permeable silicone balloon. Carbon utes. It then automatically analyzes the
dioxide is a freely diffusible gas that equili- sample with an infrared sensor and displays
brates between the gastric mucosa, the the CO2 value.
lumen and the content of the balloon.

Tonometer
balloon Stomach Gastrointestinal lumen
Gastric mucosa
CO2 CO2 Gastric mucularis
CO2
Arterial blood supply

Typical PCO2 values EtCO2 = 5.0 kPa/

38 mmHg
In a normal situation PgCO2 is slightly above
arterial PCO2. But rather than look at the
PgCO2 value, it is recommended to compare
it with either arterial PCO2 or with end-tidal
CO2.
PvCO2 = 5.8 kPa/ PaCO2 = 5.3 kPa/
44 mmHg 40 mmHg

PgCO2 = 6.0 kPa/

45 mmHg

Application Areas Benefits

Gastric tonometry is used during major Gastric tonometry provides unique diagnos-
surgery or critical care for patients suffering tic information which enables early identifi-
from shock (cardiogenic or septic), with cation of problems and earlier treatment of
severe acute respiratory failure, severe acute the patient. It can also provide a complemen-
pancreatitis, major burns and trauma pa- tary end-point for resuscitation, which
tients. improves patient management.

Tasks 9.14 Gastric Tonometry

Q1. What does gastric tonometry provide information about?

Q2. How does the CO2 get into the catheter balloon?

94 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
ANSWERS TO TASKS
Tasks 1 A9. Alveolar ventilation takes up 70 % of
the tidal volume.
Breathing is the first step
A1. The brain regulates breathing and A10. The moisture loss is normally 7 mg/l.
does this automatically.

A2. Oxygen enters the lungs and moves

Tasks 3
into the bloodstream, which carries it Circulation
to the vital organs and tissues to oxygen- A1. The two main tasks of circulation
ate them and to produce energy. are to carry oxygen to cells and
carbon dioxide to the lungs.
A3. The movement of gas into and out of
the lungs is called ventilation. A2. The circulatory system consists of the
systemic circulation that transports
Tasks 2 oxygenated blood from the heart to
organs and tissues and back to the
Respiration heart; the pulmonary circulation that
A1. The conductive airways consist of the transports deoxygenated blood from
nose, pharynx, larynx, trachea, the heart to the lungs to be oxygen-
bronchi and bronchioles. ated and returns it to the heart; and
the coronary circulation that delivers
A2. The epiglottis is a switch between blood to the heart muscle itself.
the trachea and the esophagus.
A closed epiglottis leads food into the aorta
esophagus, an open epiglottis allows
A3. superior pulmonary
vena cava artery
air to enter the lungs.
pulmonary
valve
A3. The inspiratory muscles are the LA
aortic valve
diaphragm and the external RA
tricuspid
intercostal muscles. valve LV
RV
mitral valve
A4. Spontaneous movement of molecules
inferior
from a region of higher concentration vena cava
(pressure) to a region of lower
concentration (pressure).
A4. Electrocardiogram, a recording of the
changes of electrical potential
occurring during heartbeat.
A5. Perfusion is the flow of fluid (blood)
through a vessel.
A5. The heart muscle is called the
myocardium.
A6. Ventilation and diffusion are the two
phases of respiration that precede the
entering of oxygen into the blood.
A6. The amount of blood pumped by the
heart during one minute is called the
cardiac output. It is determined by the
A7. Air volume in airways that does not
heart rate (HR) and the stroke
participate in the gas exchange.
volume (SV).

A8. Tidal volume normally takes up 10 %

of the total lung capacity.
A7. Approx 5 l/min.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 95
Tasks 4 spinal cord.
Cerebellum: balance
Oxygenation Diencephalon: controls feelings,
A1. The cardiovascular system consists of autonomic nervous system and senses
the heart function and circulation. Cerebrum: contains the cortex,
where all conscious thinking occurs.
A2. The deoxygenated hemoglobin binds
oxygen in the blood and carries it to A3. The peripheral nervous system
the tissues. consists of sensory neurons (provide
the CNS with information from the
A3. It ensures that blood flows to the periphery), and motor neurons (volun-
tissues for the resultant cellular tary or somantic neurons and involun-
uptake and utilization of oxygen. tary or autonomic neurons). Also
transports commands given by the
Tasks 5 CNS to muscles and glands.
Metabolism
A1. Oxidation is a process whereby Tasks 7
oxygen and nutrients are converted in Anesthesia Process
the body into work and heat. CO2 is a
by-product of this process and it is A1.
removed from the body quickest by
breathing. analgesia, painlessness relaxation
?
? ?
?
A2. The buffer for the CO2 is twenty times
bigger than the buffer for O2.
amnesia, forgetfulness unconsciousness
A3. Shivering and convulsions (200%)
Injury (50%) A2. Local, regional and general anesthetic
Anxiety (30%)
A3. 1. Preoperative assessment
A4. It is the respiratory quotient –the ratio 2. Preparation of the patient
of CO2 production and O2 3. Induction
consumption. It tells us the kind of 4. Maintenance
substrate that is mainly being 5. Emergence
metabolized and whether the patient 6. Recovery
is being adequately fed.
A4. Induction

Tasks 6 A5. EtO2 and I-E O2’

Neurophysiology
A1. The brain and the spinal cord are re- A6. The patient is usually connected to a
garded as the central processor of the ventilator.
body because all processing of
information occurs there. A7. Oxygen, nitrous oxide or air and
anesthetic agents.
A2. The main parts of the brain are the
brain stem: vital and other body A8. Halothane, enflurane, isoflurane,
functions such as heartbeat, sevoflurane and desflurane.
breathing, swallowing etc. and
relaying of motor and sensory impulses A9. An anesthesia machine, usually
to other parts of the brain and the including a ventilator.

96 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
A10. A non-rebreathing system and Tasks 9.1
a rebreathing system.
Ventilation; Patient Spirometry
Tasks 8 A1. It helps to optimize ventilation and to
Critical Care Process prevent and diagnose problems with
A1. The goal of critical care is to maintain the ventilator or endotracheal/trache-
vital organ function and preserve life ostomy tube.
while treating an underlying disease.
A2. The information from the ventilated
A2. In an intensive care unit, services and patient is integrated with other
essential facilities must be close. This parameters on the monitoring screen
is due to the fact that the longer the in the form of numerical and
distance, the more staff are needed for graphical information.
transportation and the risk of mishaps
is increased. A3. I:E is the ratio between inspiratory
and expiratory times. Ppeak is the
A3. The steps of critical care include maximum pressure exerted at the
admission, maintenance/restoration of patient airway. PEEP is positive end
vital organ function, treatment of main expiratory pressure. Compl, compli-
disease, prevention of additional ance, is a measure of the distensibility
damage, documentation, discharge. of the lung-thoracic system. Raw is
airway resistance.
A4. PEEP is positive end expiratory
pressure. It decreases intrapulmonary A4. Before flow can start, the pressure
shunting, increases the functional must overcome the ventilator tubing
residual capacity, improves and endotracheal tube resistance and
compliance, may improve the surface tension of alveoli.
oxygenation.
Tasks 9.2
A5. In synchronized intermittent
mandatory ventilation, the ventilator Patient Oxygen
attempts to deliver mandatory breaths A1. Without oxygen the brain may be
in synchrony with the patient’s permanently damaged after only
inspiratory effort. If there is no effort, a few minutes.
the ventilator delivers a mandatory
breath at the scheduled time. A2. Inadequate O2 supply at tissue level is
called hypoxia.
A6. In volume controlled ventilation,
the set tidal volume is delivered, but in A3. It enables the breath-to-breath ana-
pressure controlled ventilation, flow lysis of the patient’s respiratory oxygen.
depends on airway resistance and
lung compliance. Tasks 9.3
A7. Weaning from mechanical ventilation
Inhalational Anesthetic Agents
is the process of withdrawing the and N2O
patient from ventilatory support.
A1. Halothane, it does not irritate mucous
membranes. It is also a bronchodilator
and therefore good for asthma
patients.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 97
A2. Nitrous oxide is better known as Tasks 9.6
laughing gas.
Blood Pressures
A3. The most notable characteristic of A1. Blood pressure is expressed in mmHg.
sevoflurane is its low solubility in
blood, which makes it very quick in A2. The highest blood pressure is called
induction and recovery. systolic pressure and the lowest
pressure is called diastolic pressure.
A4. MAC = Minimum Alveolar
Concentration. A3. MAP is the abbreviation for mean
arterial pressure.
A5. It helps to detect misfilled vaporizers,
vaporizer contamination and situa- A4. CVP stands for central venous
tions in which two anesthetic agents pressure and it is an indicator of the
are present at the same time. ability of the right ventricle to pump
out the blood that returns from
systemic circulation to pulmonary
Tasks 9.4 circulation.
Electrocardiogram
A1. The ECG stands for electrocardio- A5. PAP is the pulmonary artery pressure.
gram. It measures and records
electrical impulses conducted through A6. PCWP is the pulmonary capillary
various parts of the heart. wedge pressure reflecting the left
ventricular preload.
A2. The names of the various waves of the
ECG are called P,Q,R,S and T waves. A7. Non-invasive blood pressure
monitoring is best suited to low-to
A3. Direction, strength and duration can medium-risk cases as it is not
be measured by ECG. continuous.

Tasks 9.5 Tasks 9.7

Cardiac Output Tissue Oxygenation – SpO2
A1. The normal value for cardiac output is A1. It is the oxygen saturation of arterial
3-7 l/min. This is affected by body blood.
size.
A2. It is both a numerical estimation of
A2. C.O. helps to evaluate blood volume SaO2 (arterial oxygen saturation)
and left ventricular function. obtained by a non-invasive optical
method and the plethysmographic
A3. A known amount of solution with a pulse waveform indicating pulsating
known temperature is injected into blood volume in the pheripheral
the right atrium (the cool solution artery.
lowers the temperature of the blood)
and then ejected from the heart into A3. Pulse oximetry measurement is
the pulmonary artery, The tempera- based on arterial blood being bright
ture is measured downstream in the red and venous blood darker.
pulmonary artery. Arteries pulsate, veins do not normally
pulsate.

98 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide
Tasks 9.8 A2. Despite large variations in ambient
temperature, body temperature is
Gas Exchange maintained within +/- 2 °C.
A1. It allows the continuous and
non-invasive monitoring of VO2 A3. Temperature can be measured e.g.
(oxygen consumption) and VCO2 from the rectum, esophagus, skin and
(carbon dioxide production) and tympanic membrane (eardrum).
therefore the computation of RQ
(respiratory quotient) and EE
(energy expenditure).
Tasks 9.12
A2. By the use of gas sensors and flow/ Neuromuscular Transmission
volume transducers to analyze the gas A1. Neuromuscular blocking agents
concentrations and volumes of prevent the normal transmission of an
expired air. impulse from the nerve to the muscle
by stopping the reflex.
Tasks 9.9
A2. The two groups of neuromuscular
Mixed Venous Oxygen Saturation blockers can be divided into two
A1. Mixed venous oxygen saturation SvO2 groups; depolarizing agents which
is the difference between arterial offer a rapid effect over a short period
oxygen saturation and body oxygen and non-depolarizing agents with a
consumption and it is measured in the longer lasting effect.
pulmonary artery.
A3. The two methods of putting an end to
A2. The normal range for SvO2 is 60-80%. the effect of neuromuscular blockers
are metabolism and administering
Tasks 9.10 reversal agents, such as neostigmine
and atropine.
Carbon Dioxide
A1. The CO2 waveform is called the
capnogram.
Tasks 9.13
A2. Ventilation, circulation and Electroencephalography
metabolism. A1. It measures the spontaneous
electrical activity of the surface layer
A3. Analyzing both the numerical and of the brain (cerebral cortex).
graphical information of EtCO2 may
indicate the actual reason for A2. Maximum recommended impedance
abnormal values. is 5 kilo-ohms. Skin may be prepared
to remove grease and dead cells from
A4. Maintaining the EtCO2 between the skin surface.
4.7-5.5 % (kPa) or 38-42 mmHg.
A3. The EEG provides information on the
Tasks 9.11 level of consciousness, level of
cerebral oxygenation and body
Temperature temperature.
A1. The body temperature is regulated in
the hypothalamus in the brain.

D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide 99
A4. Important factors that affect the
interpretation of evoked potentials are
latency, amplitude, existence and
non-existence of certain waves.

Tasks
9.14 Gastric Tonometry
A1. Gastric tonometry provides
information on adequacy of gastric
perfusion.

A2. Silicone is permeable to CO2 and CO2

is a freely diffusable gas.

APPENDIX
Conversion table for pressure units

mbar kPa torr mmHg cmH2O

_____________________________________________________________

1 0.1 0.75 0.75 1.02

10 1 7.5 7.5 10.2

1.33 0.13 1 1 1.36

1.33 0.13 1 1 1.36

0.98 0.10 0.74 0.74 1

Examples:
1 mbar = 0.1 kPa = 0.75 torr
1 mmHg = 1.33 mbar
3.4 cmH2O = 3.4 x 0.74 = 2.5 mmHg
760 mmHg = 760 x 0.13 = 101.3 kPa

100 D a t e x - O h m e d a A c a d e m y Begin n er ’s G u ide

 102
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