Intraoperative Monitoring

  • Gabriel E. Mena
  • Karthik Raghunathan
  • William T. McGee


Continuous automated ST-segment analysis is especially important during thoracic surgery given the potential for cardiac ischemia, arrhythmias, pneumothorax, severe hypoxemia, and hemodynamic instability. Oxygenation during one-lung ventilation is determined by many factors including cardiac output, blood pressure, ventilation–perfusion matching, anesthetic effects on hypoxic pulmonary vasoconstriction, airway mechanics and reactivity, oxygen consumption, and preexisting pulmonary disease. Pulse oximetry with occasional intermittent arterial blood gas analysis provides warning of significant hypoxemia. The typical CO2 vs. time waveform, displayed on most anesthesia monitors, has characteristic intervals that represent different physiologic events during ventilation. Continuous breath-by-breath spirometry (monitoring of inspiratory and expiratory volumes, pressures, and flows) enables the early detection of a mal-positioned double-lumen tube and can reduce the potential for ventilatory-induced lung injury by guiding the optimization of ventilatory ­settings. Invasive arterial pressure monitoring is commonly used to assess beat-by-beat blood pressure and it can also be used to derive functional hemodynamic information such as systolic pressure variation (SPV) and pulse pressure variation (PPV). SPV and PPV measure related aspects of cardiorespiratory interaction and these variables can predict the ability to increase cardiac output with volume loading better than central venous pressure or pulmonary artery occlusion pressure. Minimally-invasive hemodynamic monitoring (such as the Esophageal Doppler, Arterial Pressure waveform-based devices, and/or central venous oximetry) coupled with goal-directed therapy care can improve outcomes by focusing on basic clinical questions such as: “is flow (cardiac output) adequate to meet global tissue demands?”


Cardiac Output Central Venous Pressure Pulmonary Artery Catheter Fluid Responsiveness Pulse Pressure Variation 
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  1.  1.
    Wendon J. Cost effectiveness of monitoring techniques. In: Pinsky MR, Payen D, editors. Functional hemodynamic monitoring. 1st ed. New York: Springer; 2005.Google Scholar
  2. 2.
    Grocott MPW, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg. 2005;100:1093–106.PubMedCrossRefGoogle Scholar
  3. 3.
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.PubMedCrossRefGoogle Scholar
  4. 4.
    Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14.PubMedCrossRefGoogle Scholar
  5. 5.
    Kaplan J, Slinger P, editors. Thoracic anesthesia. 3rd ed. ­Philadelphia: Churchill Livingstone; 2006.Google Scholar
  6. 6.
    Schroeder RA, Barbeito A, Bar-Yosef S, Mark JB. Cardiovascular monitoring. In: Miller R, Eriksson L, Fleisher L, Wiener-Kronish J, Young W, editors. Miller’s anesthesia. 7th ed. Philadelphia: Churchill Livingstone; 2010. p. 1267–328.Google Scholar
  7. 7.
    Landesberg G, Mosseri M, Wolf Y, Vesselov Y, Weissman C. Perioperative myocardial ischemia and infarction. Identification by continuous 12-lead electrocardiogram with online ST-segment monitoring. Anesthesiology. 2002;96:264–70.PubMedCrossRefGoogle Scholar
  8. 8.
    Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. N Engl J Med. 1996;334:481–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Cannesson M, Delannoy B, Morand A, et al. Does the Pleth variability index indicate the respiratory-induced variation in the plethysmogram and arterial pressure waveforms? Anesth Analg. 2008;106(4):1189–94.PubMedCrossRefGoogle Scholar
  10. 10.
    Natalini G, Rosano A, Taranto M, et al. Arterial versus plethysmographic dynamic indices to test responsiveness for testing fluid administration in hypotensive patients: a clinical trial. Anesth Analg. 2006;103(6):1478–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Perel A. Automated assessment of fluid responsiveness in mechanically ventilated patients. Anesth Analg. 2008;106(4):1031–3.PubMedCrossRefGoogle Scholar
  12. 12.
  13. 13.
    Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin. 2008;26:241–72.PubMedCrossRefGoogle Scholar
  14. 14.
    Van Limmen JGM, Szegedi LL. Peri-operative spirometry: tool or gadget? Acta Anaesthesiol Belg. 2008;59:273–82.PubMedGoogle Scholar
  15. 15.
    Pinsky MR, Payen D. Functional hemodynamic monitoring. Crit Care. 2005;9:566–72.PubMedCrossRefGoogle Scholar
  16. 16.
    Barbeito A, Mark JB. Arterial and central venous pressure monitoring. Anesthesiol Clin. 2006;24:717–35.PubMedCrossRefGoogle Scholar
  17. 17.
    Courtois M, Fattal PG, Kovacs Jr SJ, et al. Anatomically and physiologically based reference level for measurement of intracardiac pressures. Circulation. 1995;92(7):1994–2000.PubMedGoogle Scholar
  18. 18.
    Magder S, Georgiadis G, Cheong T. Respiratory variations in right atrial pressure predict the response to fluid challenge. J Crit Care. 1992;7:76–85.CrossRefGoogle Scholar
  19. 19.
    Marik P, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134:172–8.PubMedCrossRefGoogle Scholar
  20. 20.
    The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006;354:2213–24.CrossRefGoogle Scholar
  21. 21.
    Caterino U, Dialetto G, Covino FE, et al. The usefulness of transesophageal echocardiography in the staging of locally advanced lung cancer. Monaldi Arch Chest Dis. 2007;67(1):39–42.PubMedGoogle Scholar
  22. 22.
    Arthur ME, Landolfo C, Wade M, Castresana MR. Inferior vena cava diameter (IVCD) measured with transesophageal echocardiography (TEE) can be used to derive the central venous pressure (CVP) in anesthetized mechanically ventilated patients. Echocardiography. 2009;26(2):140–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002;121:2000–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97(4):820–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds M, Bennett D. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomized, controlled trial. Crit Care. 2005;9:R687–93.PubMedCrossRefGoogle Scholar
  26. 26.
    Donati A, Loggi S, Preiser J, Orsetti G, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–24.PubMedCrossRefGoogle Scholar
  27. 27.
    Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65–71.PubMedCrossRefGoogle Scholar
  28. 28.
    Diaper J, Ellenberger C, Villiger Y, et al. Transoesophageal Doppler monitoring for fluid and hemodynamic treatment during lung surgery. J Clin Monit Comput. 2008;22(5):367–74.PubMedCrossRefGoogle Scholar
  29. 29.
    Lobo S, Lobo F, Polachini C, Patini D, et al. Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients. Crit Care. 2006;10(R72):1–11.Google Scholar
  30. 30.
    Lobo S, Salgado P, Castillo V, Borim A, et al. Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med. 2000;28(10):3396–404.PubMedCrossRefGoogle Scholar
  31. 31.
    Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103:419–28.PubMedCrossRefGoogle Scholar
  32. 32.
    Michard F, Boussat S, Chemla D, et al. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134–8.PubMedGoogle Scholar
  33. 33.
    Phan TD, Ismail H, Heriot AG, et al. Improving perioperative outcomes: fluid optimization with the esophageal Doppler monitor, a metaanalysis and review. J Am Coll Surg. 2008;207(6):935–41.PubMedCrossRefGoogle Scholar
  34. 34.
    Slinger PD, Campos JH. Anesthesia for thoracic surgery. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors. Miller’s anesthesia. 7th ed. Philadelphia: Churchill Livingstone; 2009.Google Scholar
  35. 35.
    Morgan P, Al-Subaie N, Rhodes A. Minimally invasive cardiac output monitoring. Curr Opin Crit Care. 2008;14:322–6.PubMedCrossRefGoogle Scholar
  36. 36.
    De Waal EC, Wappler F, Wolfgang F. Cardiac output monitoring. Curr Opin Anesthesiol. 2009;22:71–7.CrossRefGoogle Scholar
  37. 37.
    Manecke GR, Auger WR. Cardiac output determination from the arterial pressure wave: clinical testing of a novel algorithm that does not require calibration. J Cardiothorac Vasc Anesth. 2007;21:3–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Breukers RM, Sepehrkhouy S, Spiegelenberg SR, et al. Cardiac output measured by a new arterial pressure waveform analysis method without calibration compared with thermodilution after cardiac surgery. J Cardiothorac Vasc Anesth. 2007;21:632–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Mayer J, Boldt J, Wolf MW, et al. Cardiac output derived from arterial pressure waveform analysis in patients undergoing cardiac surgery: validity of a second generation device. Anesth Analg. 2008;106:867–72.PubMedCrossRefGoogle Scholar
  40. 40.
    Scheeren TW, Wiesenack C, Compton FD, et al. Performance of a minimally invasive cardiac output monitoring system (Flotrac/Vigileo). Br J Anaesth. 2008;101:279–80.PubMedCrossRefGoogle Scholar
  41. 41.
    Mehta Y, Chand RK, Sawhney R, et al. Cardiac output monitoring: comparison of a new arterial pressure waveform analysis to the bolus thermodilution technique in patients undergoing off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2008;22:394–9.PubMedCrossRefGoogle Scholar
  42. 42.
    McGee WT. A simple physiologic algorithm for managing hemodynamics using stroke volume and stroke volume variation. J Int Care Med. 2009;24(6):352–360.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Gabriel E. Mena
    • 1
  • Karthik Raghunathan
    • 2
  • William T. McGee
    • 3
    • 4
  1. 1.Department of Anesthesiology and Pain MedicineMD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Anesthesiology, Baystate Medical CenterTufts University School of MedicineSpringfieldUSA
  3. 3.ICU Quality Improvement, Critical Care Division, Department of Medicine and SurgeryBaystate Medical CenterSpringfieldUSA
  4. 4.Tufts University School of MedicineBostonUSA

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