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Basic patient monitoring during anesthesia

Author: Gabriella Iohom, MD, PhD
Section Editor: Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2022. | This topic last updated: Jun 14, 2022.

INTRODUCTION

Monitoring is an essential component of’ anesthesia care. Anesthesia clinicians must monitor
patient physiologic variables and anesthesia equipment during all types of anesthesia, as
anesthesia and surgery can cause rapid changes in vital functions. Patient and equipment
monitoring is used to titrate administration of anesthetic medication, to detect physiologic
perturbations and allow intervention before the patient suffers harm, and to detect and correct
equipment malfunction.

This topic will discuss the basic patient monitors used during anesthesia. Monitoring
neuromuscular blockade, transesophageal echocardiography (TEE), monitoring to prevent
awareness during anesthesia, neuromonitoring during anesthesia and surgery, and pulmonary
artery catheter monitoring are discussed separately.

● (See "Monitoring neuromuscular blockade".)

● (See "Transesophageal echocardiography: Indications, complications, and normal views".)
● (See "Pulmonary artery catheterization: Indications, contraindications, and complications
in adults".)
● (See "Accidental awareness during general anesthesia", section on 'Monitoring'.)
● (See "Neuromonitoring in surgery and anesthesia".)

STANDARDS FOR MONITORING DURING ANESTHESIA

The term "standard ASA monitors" is often used to refer to the basic physiologic monitors
recommended by the American Society of Anesthesiologists [1]. Standard ASA monitors applied
to the patient include a pulse oximeter, electrocardiography (ECG), noninvasive blood pressure
device, and a temperature monitor. In addition, the ASA monitoring standards include
measurement of end-tidal carbon dioxide (ETCO2), inspired oxygen concentration, and the use
of low oxygen concentration and ventilator disconnect alarms. Quantitative monitoring of the
volume of expired gas is strongly encouraged by the ASA. According to the ASA standards for
monitoring, continual monitoring is defined as measurement repeated regularly and frequently
in steady, rapid succession (eg, automatic noninvasive blood pressure measurement), whereas
continuous monitoring is that which is prolonged, without interruption (eg, ECG monitoring).

The standards for monitoring during anesthesia created by international anesthesia

organizations are shown in a table ( table 1) [2-6]. All of these standards state that the most
important monitor is the presence of an anesthesia clinician throughout anesthesia, and
include statements that a blood pressure monitor, pulse oximeter, and ETCO2 monitor should
be used during anesthesia.

MONITORING MODALITIES

Clinician monitoring — Clinical monitoring using visual inspection, auscultation, and palpation
is a primary determinant of patient safety. Changes in clinical signs may be subtle, and often
precede abnormalities in parameters measured by monitoring devices. Monitoring devices do
not replace clinical observation; rather, they amplify and quantify clinical information
( table 2).

Respiratory system monitoring

Oxygenation

Cyanosis — Clinical assessment of hypoxemia judged by perioral cyanosis is known to be

notoriously unreliable. Many factors such as natural skin pigment, room lighting, interobserver
variation, and hemoglobin concentration can affect detection of cyanosis. Approximately 5 g/dL
of unoxygenated hemoglobin in the capillaries generates the dark blue color appreciated
clinically as cyanosis [7]. However, this threshold may occur at varying levels of arterial oxygen
saturation and arterial hemoglobin content, as shown in a figure ( figure 1).

Pulse oximetry — Pulse oximetry is a quantitative method of assessing oxygenation that

should be used when possible during all anesthetics, and is part of the World Health
Organization preoperative safe surgery checklist [8]. If pulse oximetry cannot be used during
induction of anesthesia (eg, in small children, with uncooperative adults), the monitor should be
attached as soon as consciousness is lost and the reason for the delay should be recorded in the
anesthesia record. Importantly, the variable pitch pulse tone and the low threshold alarm
should be audible to the anesthesia clinician.

The principles of pulse oximetry, equipment, accuracy, and sources of error are discussed
separately ( table 3). (See "Pulse oximetry", section on 'Probes'.)

In the operating room, pulse oximeters are commonly placed on the finger or earlobe in adults,
and on the foot/ankle or wrist/palm in infants, to shine light through tissue and detect it on the
other side. Newer forehead probes use reflectance technology to measure back scattered rather
than transmitted light. The response time to changes in oxygen saturation is faster with
forehead and ear probes than with finger probes. (See "Pulse oximetry", section on 'Probes'.)

Most pulse oximeters display a plethysmographic (pleth) waveform ( figure 2). The practical
purpose of displaying the pleth waveform is to verify good probe placement and function. In
commercially available pulse oximeters, the waveform is only processed to determine heart
rate. Most pulse oximeter monitors display an indicator of the quality of the signal; a good
signal indicates that the oximeter is working.

The pleth waveform resembles an intraarterial wave form, and advanced analysis may similarly
provide additional clinical information. One specialized monitor incorporates an algorithm to
measure changes in the pulse volume continuously, to determine the plethysmographic
variability index (PVI). The PVI is a measure of the dynamic changes in the perfusion index over
respiratory cycles, with the goal of predicting fluid responsiveness [9]. (See "Novel tools for
hemodynamic monitoring in critically ill patients with shock", section on 'Pulse contour analysis
(fluid responsiveness)' and "Intraoperative fluid management", section on 'Goal-directed fluid
therapy'.)

The utility of the PVI for predicting intraoperative fluid responsiveness is unclear. A meta-
analysis of 10 small studies that compared PVI with cardiac output or stroke volume based
measures of fluid responsiveness found that PVI was reasonably accurate at predicting fluid
responsiveness in mechanically ventilated adults [10]. PVI is not reliable in patients with atrial
fibrillation or arrhythmias, and is affected by changes in peripheral perfusion (eg, use of
vasoconstrictors, or cold extremities).

Respiratory variation in pulse volume changes with ordinary pulse oximeters are rarely visible,
and are a crude and late indicator of massive hypovolemia.
 Inspired oxygen analyzer — During every general anesthetic employing an anesthesia
machine, an oxygen analyzer should be used to ensure that a hypoxic mixture of gases is not
delivered. The analyzer is calibrated by exposure to air (21 percent oxygen [O2]) and 100 percent
O2, and should read 21 percent before each anesthetic when open to room air. O2 analyzers
usually have a low-level alarm that is automatically activated by turning on the anesthesia
machine. The sensor should be placed into the inspiratory or expiratory limb of the breathing
circuit and not into the fresh gas flow, to ensure measurement of the concentration actually
delivered, rather than the dialed concentration.

Most modern anesthesia gas analyzers incorporate methods allowing simultaneous

measurement of concentrations of at least O2, carbon dioxide (CO2), and the inhalation agent.
Non-dispersive infrared spectroscopy is usually employed, and gas analyzers that measure
oxygen utilize ancillary technologies such as paramagnetic or fuel-cell sensors in conjunction
with the infrared sensor. (See "Accidental awareness during general anesthesia", section on
'End-tidal anesthetic concentration'.)

Ventilation — Adequacy of ventilation should be continuously monitored in all patients during

anesthesia, including observation of clinical signs such as chest excursion, auscultation of
breath sounds (using a precordial or esophageal stethoscope), and movement of the reservoir
bag. Patients who are breathing spontaneously should be observed for signs of airway
obstruction, including a tracheal tug, paradoxical chest movement, snoring, or upper airway
sounds.

During anesthesia without sedation (ie, regional or local anesthesia without sedation), clinical
observation may be adequate for monitoring ventilation.

Capnography — Most anesthesia machines are capable of providing an exhaled

capnograph, which is a graph that shows the respiratory rate and the concentration of carbon
dioxide over time, as well as the end-tidal carbon dioxide concentration (ETCO2). Capnography
should be used to assess the adequacy of ventilation for all patients who undergo sedation or
general anesthesia, if possible. Capnography should also be used to confirm correct placement
of an endotracheal tube or supraglottic airway.

● The principles of operation of exhaled carbon dioxide monitors are discussed separately.
(See "Carbon dioxide monitoring (capnography)", section on 'Principles of operation' and
"Carbon dioxide monitoring (capnography)", section on 'CO2 Waveform'.)

Most CO2 analyzers used in the operating room sample gas via a sidestream mechanism.
This means that the CO2 sensor is part of the anesthesia machine, and gas is aspirated
through sampling tubing connected to the patient breathing circuit. Sample tubing may be
 six or more feet long, and there may be a several second delay before appearance of the
CO2 trace after a breath.

● The phases of the normal capnogram are shown in a figure ( figure 3). The continuous
wave form allows a visual breath to breath assessment of the patient’s airway and
ventilation. Changes of the shape of the capnogram can be the result of patient factors
(eg, small or large airway obstruction, intrinsic lung disease, or ventilatory effort),
equipment malfunction (eg, breathing circuit leak), or surgical manipulation. Examples of
normal and abnormal capnograms are shown in a figure ( figure 4).

In general, when square wave capnography is preserved during mechanical ventilation,

• A sudden drop in ETCO2 suggests a sudden drop in lung perfusion caused by either an
obstruction to blood flow through the lungs (thrombus, air, or fat) or a reduction in
cardiac output.

• Steady increase in ETCO2 suggests hypoventilation or very rarely malignant

hyperthermia if associated with rise in temperature.

● Correlation with PaCO2 – The ETCO2 is a non-invasive estimate of the CO2 concentration
or partial pressure in the arterial blood (PaCO2) [11]. This is based on the assumption that
end-tidal gas is primarily alveolar gas and alveolar CO2 tension (PACO2) is virtually identical
to pulmonary end-capillary tension, which in turn is identical to PaCO2. The PACO2-PETCO2
gradient in a healthy patient with normal lungs is less than 5 mmHg and represents
dilution of alveolar gas with CO2-free gas from non-perfused alveoli (alveolar dead space)
[12]. The difference is increased if there is a mismatch between ventilation and perfusion
(V/Q) of the lungs, as seen in patients with lung disease, pulmonary emboli, low-cardiac
output states, and hypotension [11], but may also be variably increased because of
advanced age, and with surgical positioning [13,14]. For this reason, PaCO2 should be
measured when close control of ventilation is necessary (eg, patients with increased
intracranial pressure).

In patients with obstructive lung disease and an upsloping ETCO2 plateau, inspiration may
occur before the true end of expiration, and result in a falsely low ETCO2 (in addition to
predisposing to dynamic hyperinflation) ( figure 5). Reducing the respiratory rate (or
briefly stopping the ventilator) should allow full exhalation and an accurate ETCO2 reading.

Measurement of pulmonary mechanics — Most newer anesthesia machines provide the

capability to continuously monitor inspiratory and expiratory volumes, pressures, and flow and
to display pressure volume loops and flow volume loops. The use of these parameters to
optimize ventilator settings, and to monitor changes in pulmonary mechanics are discussed
separately. (See "Mechanical ventilation during anesthesia in adults", section on 'Monitoring
pulmonary mechanics'.)

● Airway pressure – Airway pressure should ideally be measured in the trachea. However,
for practical reasons pressure is measured at the anesthesia machine with pressure
transducers. The most commonly used transducer is the inexpensive, piezo-resistive
transducer that relies on a pressure sensing diaphragm whose resistance changes when it
is deformed in response to a differential pressure. The pressure transducers must be
zeroed at the beginning of each day as part of the pre-use checkout. Inaccuracies or even
failures may occur when humidity condenses in the pressure transducer tubing. Because
the transducers are hidden in the machine, a leak in the breathing system because of a
cracked transducer may not be obvious to the clinician [15].

● Gas flow – The two main methods for measurement of flow on contemporary anesthesia
workstations are hot wire anemometers and variable orifice sensors.

• Hot wire anemometers – Gas flows past and cools a thin wire that is heated to maintain
a constant temperature. The heating current required is therefore related to gas flow.
Changes in gas composition (density) affect the accuracy of this design of flowmeters.

• Variable orifice flow sensor/differential pressure – The pressure difference across a

variable size orifice is used to infer gas flow.

● Respiratory volume – The anesthesia machine software computes the respiratory volume
by integrating the flow with respect to time (flow = volume/time).

Disconnection alarms — Most anesthesia machines automatically set alarm limits for
changes in respiratory rate and pressure that serve as disconnect alarms. An audible signal
occurs if the limits are exceeded. Alarms can be changed manually according to clinical
circumstances.

Circulatory system monitoring — Adequacy of circulatory function is assessed by both clinical

observation and physiologic monitors. Assessment of skin color and temperature, the quality of
a palpable pulse, and heart tones via an esophageal or precordial stethoscope are valuable
clinical parameters that must be supplemented by measurement of blood pressure, heart rate,
electrocardiography (ECG), and in some cases, advanced cardiovascular monitoring. Urine
output may also be used to assess organ perfusion.
Adequate lighting should be maintained in the operating room to allow observation of exposed
body parts.

Blood pressure — Blood pressure (BP) and heart rate should be measured at least every five
minutes during anesthesia, and more frequently as indicated clinically. In practice, heart rate is
continuously monitored by ECG and the pulse oximeter, and by the arterial pressure trace if
invasive BP monitoring is used.

Noninvasive blood pressure monitoring — The standard device for intraoperative

noninvasive BP monitoring is the automated office BP monitor. A sphygmomanometer should
be available for situations in which an oscillometric reading cannot be obtained.

● Technology – Oscillometric BP devices operate by sensing the magnitude of oscillations in

pressure caused by the blood flow. The cuff is inflated by a pump high enough to occlude
arterial flow to the limb, and then released gradually, typically at approximately 2 to 4
mmHg per second [16]. A sensor in the device detects changes in oscillations, or amplitude
of pressure pulses, created by the blood flow as the occlusion is released. Very faint blood
flow oscillations begin to be detected as the pressure in the cuff coincides with systolic
blood pressure (SBP). As pressure is released, the amplitude of pulsatile oscillations
increases to a maximum that corresponds with mean arterial pressure (MAP), and
ultimately levels off at a pressure that indicates diastolic pressure. Oscillometric BP devices
are set to "time out" (ie, not display a reading) at 120 seconds if the measurement cannot
be made.

● Cuff size and placement – The proper cuff size should be used for the most accurate
blood pressure measurement. The length of the cuff bladder should be 80 percent, and
the width 46 percent of the circumference of the upper arm. (See "Blood pressure
measurement in the diagnosis and management of hypertension in adults", section on
'Cuff size'.)

In most patients, this means that the cuff covers two-thirds of the distance between the
elbow and shoulder. The cuff should be placed on the bare skin of the upper arm, snugly
applied with the mid-bladder (sometimes marked) over the brachial artery.

When necessary, the blood pressure cuff can be placed on the forearm, ankle, calf, or
thigh. The cuff size should be chosen as it would be for the arm (ie, related to the
circumference of the limb). An ankle cuff should be placed as far distally as possible, with
the mid-bladder just behind the medial malleolus. For measurement at the calf or thigh,
the mid-bladder should be placed posteriorly.
● Accuracy – Systolic and diastolic blood pressures with oscillometric devices are calculated
according to proprietary algorithms that vary by manufacturer, hence their accuracy
depends on the algorithm used. Oscillometric methods tend to overestimate SBP and
underestimate diastolic blood pressure (DBP), whereas they more accurately estimate
mean arterial pressure (since this corresponds to a maximum amplitude of pulsatile
oscillations) [17,18].

Although the accuracy of non-invasive blood pressure (NIBP) measurement is excellent

over a wide range of blood pressures, its accuracy with very low or very high blood
pressure remains questionable, compared with auscultatory and invasive arterial BP
measurements [19]. As examples, oscillometric automated measurements are consistently
higher than ausculatory measurements in trauma patients with systolic blood pressure
less than 110 mmHg [20]. An analysis of 27,022 simultaneously measured invasive arterial
and non-invasive BP (NIBP) pairs reported that in hypotensive states, the NIBP significantly
overestimated the systolic blood pressure, and this difference increased as patients
became more hypotensive [21]. Mean arterial blood pressures showed better agreement.

Aside from errors intrinsic to the technology, the most common source of error with the
use of non-invasive blood pressure measurement is an inappropriate cuff size. Cuffs that
are too large produce erroneously low oscillometric readings, and cuffs that are too small
produce higher readings. (See "Blood pressure measurement in the diagnosis and
management of hypertension in adults", section on 'Cuff size'.)

Other factors that may lead to errors or prevent measurement with a noninvasive blood
pressure cuff include the following:

• Any motion such as shivering, tremors, seizures, or arm flexion

• Severe hypotension
• Arrhythmias such as atrial fibrillation or frequent premature beats
• Air leak, kink, or alteration of the cuff or tubing.
• Rapidly repeated cuff inflations, which can cause venous congestion [22]

Blood pressure measured at other sites may not correlate with measurements in the
upper arm. Studies of comparative measurements in the arm and ankle or calf have
reported conflicting and widely variable results, and have been performed in
heterogeneous patient populations [23-26]. If the cuff must be placed on the leg, when
possible a baseline measurement in the arm should be performed first for comparison.

Systolic, diastolic, and mean blood pressure measurements with the cuff on the forearm
tend to be higher than measurements in the upper arm [27,28]. (See "Anesthesia for the
 patient with obesity", section on 'Special equipment needs'.)

Blood pressure measurement should be corrected for patient position, particularly if the
patient is placed in steep head up, steep head down, or sitting positions. Hydrostatic
effects cause an increase in measurements in dependent limbs, and a decrease in
measurements in elevated limbs. This difference may have important clinical implications.
As an example, a patient in the sitting position with a normal mean arterial pressure
measured in the arm may have unacceptably low mean arterial pressure in the brain. (See
"Patient positioning for surgery and anesthesia in adults", section on 'Physiologic effects of
sitting position'.)

● Continuous noninvasive blood pressure monitoring – Several devices are available for
continuous noninvasive blood pressure monitoring. Examples include the Clearsight and
CNAP systems, which use volume clamp technology with a small finger cuff, and the T-line
system that uses arterial tonometry at the radial artery. These devices should not routinely
replace intraarterial pressure monitoring for patients who require continuous blood
pressure monitoring. Their utility in routine practice has not been defined [29].

• Accuracy of these devices compared with invasive arterial pressure monitoring in the
perioperative period does not meet standards set by the Association for the
Advancement of Medical Instrumentation [30].

• Accuracy of these devices may degrade during hypotension and conditions that affect
peripheral perfusion [31].

• Accuracy of other hemodynamic parameters reported by these devices (eg, cardiac

output, stroke volume) is insufficient to guide goal directed fluid therapy [32].

Invasive blood pressure monitoring — Direct or invasive blood pressure monitoring may
be used for anesthesia for high risk patients and/or high risk surgical procedures. Techniques
for catheterization, interpretation of the arterial waveform, accuracy, and sources of error are
discussed separately. (See "Intra-arterial catheterization for invasive monitoring: Indications,
insertion techniques, and interpretation".)

We place a non-invasive blood pressure cuff for patients in whom we use intraarterial
monitoring to compare measurements and to serve as a backup should technical problems
occur. We measure a noninvasive pressure after the arterial catheter is placed and the
transducer is zeroed and leveled, expecting mean pressures to be similar, and make
adjustments as necessary. We then set the noninvasive cuff to cycle at 30 minute intervals.
 Electrocardiogram — The ECG should be monitored continuously during anesthesia. It is a
reliable monitor for heart rate, rhythm, and the cardiac conduction system; the ability of the
standard three or five lead ECG to detect intraoperative cardiac ischemia is limited.
Abnormalities of the ECG may also provide evidence of electrolyte abnormalities. The
components of the ECG and the basics of interpretation are discussed separately. (See "ECG
tutorial: Electrical components of the ECG" and "ECG tutorial: Basic principles of ECG analysis".)

ECG leads — The standard ten electrode, twelve lead ECG that is used in other clinical
settings is usually impractical in the operating room. Instead, three or five leads are usually
applied. Whenever possible, a five lead system should be used to display two channels and
improve the sensitivity for detection of ischemia.

● Five electrode system – The five electrode system includes four extremity (ie, right arm,
left arm, right leg, left leg) and one precordial electrode, and allows monitoring of seven
leads (I, II, III, aVR, aVL, aVF, and a single precordial lead). The desired precordial lead may
be selected by placing the precordial electrode in any position from V1 to V6. (See "ECG
tutorial: Electrical components of the ECG", section on 'Precordial leads'.)

For continuous ECG monitoring in the operating room (and in other parts of the hospital),
the limb leads are typically placed on the torso. The arm leads are placed in the
infraclavicular fossae close to the shoulders, and the left leg lead is placed below the rib
cage in the anterior axillary line. The right leg electrode is a ground that can be placed
anywhere, and is often placed on the right chest or abdomen.

Most monitors allow selection and display of multiple leads simultaneously. We usually
select leads II and V5.

● Three electrode system – The three electrode system allows monitoring along one
bipolar lead between two electrodes while the third serves as a ground. Electrodes are
placed in the infraclavicular fossae on left and right sides, and the left leg electrode is
placed on the left side of the abdomen below the ribcage. Three leads may be individually
selected with monitor controls. The three lead system can be used to monitor heart rate
and to detect the existence of a p wave or presence of ventricular fibrillation, but cannot
diagnose more complicated arrhythmias or conduction system abnormalities, for which a
true V1 lead is required (eg, to distinguish between right and left bundle branch blocks).

The three lead system may be modified to approximate standard precordial leads by
changing the standard electrode position. Such modification may be necessary if a five
lead system is unavailable, or cannot be used because of the site of surgery, though the
five lead system is the standard of care for ischemia monitoring [33]. A three electrode
 ECG only allows for identification of ischemia and myocardial infarction in myocardial
regions represented in the selected leads, and many perioperative ischemic events will be
missed when using three electrode recordings.

Three modified leads can be used to monitor for anterior ischemia. For each of these
leads, limb lead I is selected on the monitor, and the electrodes are placed as follows:

• CS5 – The right arm (RA) electrode is placed under the right clavicle, left arm (LA)
electrode is placed in the V5 position, and the left leg (LL) electrode is placed anywhere
on the left side.

• CM5 – The RA electrode is placed over the manubrium, the LA electrode is placed in the
V5 position, and the LL electrode can be placed anywhere on the left.

• CC5 – The RA electrode is placed in the mid-chest at the right anterior axillary line, the
LA electrode is placed at the V5 locations, and the LL electrode is placed anywhere on
the left.

• CB5 – The RA electrode is placed over the center of the right scapula, the LA electrode is
placed in the V5 position, and the LL electrode is placed anywhere on the right side.
CB5 can be used to monitor for dysrhythmias, since it provides an obvious p wave.

The modified chest lead 1 (MCL1) provides p wave and QRS morphology adequate to
detect some dysrhythmias. The LA electrode is placed below the left clavicle, the LL
electrode is placed in the V2R to V3R location (ie, V2 and V3 on the right chest), and the RA
electrode is placed anywhere on the right side. Limb lead III is selected on the monitor.

Ischemia detection — For optimal detection of ischemia, more than one lead should be
monitored, including an accurately placed precordial electrode. The changes visible on the ECG
monitor may be subtle and difficult to quantify. Suspected ischemia should be confirmed with
printout of a paper copy of the ECG trace, which is possible with most anesthesia monitors.
Detailed perioperative ECG analysis should always be performed on ECG printouts because
monitors do not provide grids for adequate analysis. In high risk patients, a baseline ECG strip
should be printed prior to induction of anesthesia for later comparison if necessary.

Most intraoperative ischemia is manifested by ST depression [34,35]. ECG criteria for diagnosing
ischemia are discussed separately. (See "ECG tutorial: Myocardial ischemia and infarction".)

● Lead combinations – Lead II is usually monitored for rhythm detection, since the p wave
is typically obvious and upright in lead II, and for detection of inferior ischemic changes. In
addition, a lateral precordial lead should be monitored. In one study, high risk patients
 who underwent noncardiac surgery were monitored for ST segment changes with
combinations of ECG leads, compared with continuous simultaneous 12 lead ECG
monitoring [34]. Sensitivity for a single lead was highest for V5 (75 percent). The
combination of lead II with V5 increased sensitivity for ischemia detection to 80 percent,
and the sensitivity of three lead combinations was highest (96 percent) for leads II, V4, and
V5. In another study, lead V4 was the most sensitive lead when monitored in isolation for
detecting prolonged postoperative ischemia and infarction [35].

● ST segment analysis – Most anesthesia monitors now allow real-time ST segment analysis
with trending. The default setting for ST segment analysis is usually for the device to
measure deviation of the ST segment from isoelectric at 60 or 80 msec after the J point on
the ECG trace (ie, J+60). Among the precordial leads (V3 to V5), monitoring the lead with
the most isoelectric ST segment on the preoperative ECG may increase the utility of ST
segment analysis [35].

The measurement point, and the J Point, may be adjusted manually to improve accuracy of
ST segment analysis for patients with abnormal ECGs. In patients without isoelectric ST
segments, the alarm limits should be configured to account for the patient’s baseline
deviation. A number of conditions may affect the ST segment and reduce the utility of ST
segment analysis for ischemia detection, such as left bundle branch block, Wolff-
Parkinson-White syndrome, hypokalemia, digitalis, and left ventricular hypertrophy.

Sources of ECG artifact — A number of factors can affect the ECG trace in the operating
room. Some may be modified to improve the ECG trace, whereas others cannot. They include
the following:

● Electrodes may lose contact with the skin because of inadequate skin preparation prior to
placement, tension on the lead wire, or the surgical skin preparation solution, irrigant, or
blood seeping under the lead.

● The ECG baseline can wander because of shivering, tremor, respiration, or body movement
associated with surgery. Baseline wandering may also be the result of poor electrode
contact or electrode placement over bony prominences. Selecting a monitoring filter,
rather than a diagnostic filter, on the ECG monitor may reduce wandering. (See
'Monitoring modes' below.)

● The ECG trace may be obliterated during electrosurgery. Such interference can be
minimized by placing the grounding pad on the leg, when appropriate. Safety issues
related to electrosurgery are discussed separately. (See "Overview of electrosurgery",
section on 'Improving safety'.)
 ● The ECG trace may be affected by electrical interference from devices in the operating
room. When possible, plugging devices into outlets away from the anesthesia machine or
on separate electrical circuits may resolve this type of interference.

● The amplitude of the ECG trace may be reduced in patients with obesity, as increased
thoracic wall thickness may attenuate transmission.

Monitoring modes — Most ECG monitors allow the clinician to select among at least
two monitoring modes that set filters for different signal frequencies to reduce electrical
interference, in addition to pacemaker detection mode.

The frequency bandwidths for the monitor and diagnostic modes vary by manufacturer, and are
different for adults and neonates.

● Monitor mode – Monitor mode is particularly useful for rhythm monitoring, in which
noise can be distracting and ST segment interpretation is relatively less important. High
and low pass filters are set for a bandwidth between 0.5 and 40 Hz for adults. A
disadvantage of this mode is that pacemaker spikes are sometimes filtered out and not
visible on the monitor. This mode may help reduce baseline wandering.

● Diagnostic mode – Diagnostic mode is useful for ST segment analysis. The bandwidth for
adults is typically 0.05 to 100 Hz.

● Pacemaker detection – A variety of both hardware and software methods may be used by
monitor manufacturers to filter noise and enhance the pacemaker spike [36].

Other monitors of circulation — Clinical use of advanced cardiovascular monitoring is

discussed separately, in the UpToDate topics on clinical scenarios in which they are frequently
used. (See "Anesthesia for cardiac surgery: General principles", section on 'Monitoring' and
"Anesthesia for open abdominal aortic surgery", section on 'Monitoring'.)

Ultrasound may be used to detect pulses that are not readily palpable, such as in patients with
obesity, pediatric patients, or patients in shock. Continuous ultrasound monitoring for
peripheral pulses is not widely available.

● Central venous catheters – Central venous pressure (CVP) monitoring is no longer

routinely used to guide intraoperative fluid replacement. CVP is an inaccurate surrogate
for cardiac preload, and does not detect or predict impending pulmonary edema indicative
of hypervolemia. (See "Intraoperative fluid management", section on 'Traditional static
parameters'.)
 Central venous catheters may be inserted for secure intravascular access, for
administration of concentrated vasopressors, and/or to allow placement of a pulmonary
artery catheter.

● Pulmonary artery catheters – In selected patients, a pulmonary artery catheter (PAC)

may be inserted to provide dynamic information regarding pulmonary artery pressure
(PAP), cardiac output (CO), and mixed venous oxygen saturation (SVO2). Routine use of
pulmonary artery catheters has fallen out of favor, because of lack of evidence for
mortality benefit in surgical patients. (See "Anesthesia for cardiac surgery: General
principles", section on 'Intravascular cardiac monitors'.)

Techniques for insertion, indications and contraindications, and interpretation of data

provided by PACs are discussed in detail separately. (See "Pulmonary artery
catheterization: Indications, contraindications, and complications in adults" and
"Pulmonary artery catheters: Insertion technique in adults" and "Pulmonary artery
catheterization: Interpretation of hemodynamic values and waveforms in adults".)

● Intraoperative transesophageal echocardiography (TEE) – TEE involves insertion of a

miniaturized ultrasound probe into the esophagus to visualize the heart. Compared with
transthoracic echocardiography, TEE provides superior views of posterior cardiac
structures, and facilitates continuous monitoring. Intraoperative TEE is discussed in detail
separately. (See "Intraoperative transesophageal echocardiography for noncardiac
surgery" and "Intraoperative rescue transesophageal echocardiography (TEE)".)

● Other hemodynamic (CO) monitors – A number of noninvasive devices are available for
intraoperative CO monitoring, including Doppler-based technologies, pulse contour
(arterial waveform) analysis, and thoracic impedance devices.

Doppler-based techniques appear to achieve accuracy similar to thermodilution

pulmonary artery catheters. Pulse contour (arterial waveform) analysis and thoracic
impedance devices have not been studied as rigorously, but the majority of studies
suggest that they are less accurate [37].

These devices provide real time estimates of cardiac output, stroke volume, and systolic
flow time. Trends in these variables, and respiratory variation in stroke volume and pulse
pressure, can be used to guide intraoperative fluid therapy. (See "Intraoperative fluid
management", section on 'Dynamic parameters to assess volume responsiveness'.)

• Transesophageal Doppler – Transesophageal Doppler (TED) measures blood-flow

velocity in the descending thoracic aorta using a flexible probe which contains a
 Doppler transducer in its tip. (See "Novel tools for hemodynamic monitoring in critically
ill patients with shock", section on 'Aortic Doppler'.)

TED requires training, and results depend on user expertise and accurate probe
positioning. The position of the probe may require frequent adjustment, particularly if
patient position is changed during surgery. The device can only be used in sedated or
anesthetized patients, and is generally not continued into the post anesthesia care unit.
TED may be less accurate in some patients. As an example, the calculations assume
that approximately 70 percent of cardiac output enters the descending aorta, which
may not be accurate in hypovolemic patients whose blood flow is redirected to the
cerebral circulation.

• Pulse contour (arterial pulse waveform) analyzers – These devices estimate cardiac
output by analyzing the shape of the waveform from an intraarterial catheter. (See
"Novel tools for hemodynamic monitoring in critically ill patients with shock", section
on 'Arterial waveform-based devices'.)

• Thoracic impedance monitors – These devices are not widely used in the operating
room. They use the principle that as the amount of blood in the thorax varies with each
heartbeat, it causes a corresponding change in the electrical conductance of the
thorax. (See "Novel tools for hemodynamic monitoring in critically ill patients with
shock", section on 'Thoracic electrical bioimpedance or bioreactance'.)

• Plethysmographic waveform – The plethysmographic (pleth) waveform displayed by a

pulse oximeter is analyzed by some monitors to predict fluid responsiveness. (See
'Pulse oximetry' above.)

Temperature monitoring — We agree with the American Society of Anesthesiologists’

standards for monitoring temperature, which state that every patient should have temperature
monitored when clinically significant changes in body temperature are intended, anticipated, or
suspected [38]. In practice, this means that temperature should be monitored for most patients
who have general anesthesia lasting more than 30 minutes, or major surgery with neuraxial
anesthesia [39]. Patient temperature should be monitored to detect changes (usually
hypothermia), to guide thermal management, and to detect malignant hyperthermia. Core
temperature should be monitored intraoperatively whenever possible; the optimal monitoring
site depends on the surgical procedure and type of anesthesia [40]. (See "Perioperative
temperature management".)

Temperature monitoring sites — Core temperature is monitored at highly perfused sites

where temperature is homogeneous and high compared with other sites. Core temperature is
monitored with nasopharyngeal (with probe inserted 10 to 20 cm), distal esophageal, tympanic
membrane, or pulmonary artery probes [41]. Nasopharyngeal or esophageal probes are used
routinely during general anesthesia.

Alternative temperature monitoring sites may be required during some procedures (eg, oral or
esophageal surgery), for patients who have regional anesthesia, or during general anesthesia
with a face mask or supraglottic airway for airway management. Outside the United States, a
double-sensor thermometer is applied to the forehead. Several studies have reported that this
type of monitor correlates well with other methods of core temperature measurement during
anesthesia [42,43].

Axillary, bladder, and rectal temperature may reasonably estimate core temperature, though
each site is subject to possible artifact.

● Axillary temperature is most accurate with the probe positioned over the axillary artery,
and with the arm at the patient's side [44]. In one study, a novel wireless temperature-
monitoring device taped to shaved skin over the axillary artery closely approximated
simultaneously-measured core temperature during general anesthesia for noncardiac
surgery, with mean difference (esophageal minus axillary) of 0.14ºC ± 0.26ºC [45].

● Bladder temperature correlates with rectal temperature, and accuracy is affected by urine
flow [46].

● Rectal temperature may accurately reflect core temperature [41], but changes slowly
during rapid changes in body temperature, and may not increase rapidly during malignant
hyperthermia crises [47]. Rectal temperature is rarely monitored because of the risk of
rectal perforation with the probe.

Equipment — Most of the temperature probes used in anesthesia for nasopharyngeal,

esophageal, and axillary sites are thermistors, which are semiconductors whose electrical
resistance decreases with temperature. They are usually coated with a smooth plastic layer to
facilitate atraumatic insertion, and are disposable. Temperature probes embedded in Foley
catheters are used to monitor bladder temperature.

Tympanic membrane probes are soft-tipped thermocouple devices that are inserted into the
auditory canal to rest against the tympanic membrane. These devices are distinct from and
much more accurate than tympanic membrane infrared scanners, and provide real time
continuous measurement of core body temperature [48].
The temporal artery and tympanic infrared scanners that are increasingly used in recovery areas
are not sufficiently accurate for monitoring during anesthesia [49,50].

Temperature measurement during cardiopulmonary bypass is discussed separately. (See

"Management of cardiopulmonary bypass", section on 'Temperature'.)

Other monitors — Intraoperative use of cerebral oximetry, transcranial Doppler, and jugular
venous bulb monitoring are discussed separately. (See "Anesthesia for aortic surgery requiring
deep hypothermia", section on 'Cerebral oximetry' and "Anesthesia for patients with acute
traumatic brain injury", section on 'Monitoring'.)

SUMMARY AND RECOMMENDATIONS

● Standard monitors – The standard monitors applied to the patient during anesthesia
include a pulse oximeter, electrocardiography, noninvasive blood pressure device, and a
temperature monitor. Standard equipment monitors include measurement of end-tidal
carbon dioxide (ETCO2), inspired oxygen concentration, and the use of low oxygen
concentration and ventilator disconnect alarms. (See 'Standards for monitoring during
anesthesia' above.)

Clinical monitoring using visual inspection, auscultation, and palpation is a primary

determinant of patient safety.

● Respiratory monitors

• Pulse oximeters provide an objective measure of oxygenation and display a

plethysmographic waveform that is processed to determine heart rate. An inspired
oxygen analyzer should be used during every anesthetic in which an anesthesia
machine is used. (See 'Pulse oximetry' above and 'Inspired oxygen analyzer' above.)

• Ventilation during anesthesia is assessed clinically (ie, by observation of chest

excursion, auscultation of breath sounds, movement of the reservoir bag), and by
capnography. Capnography can be used to detect clinical changes (eg, small or large
airway obstruction, intrinsic lung disease, or ventilatory effort) and/or equipment
malfunction (eg, breathing circuit leak, or kinked endotracheal tube). (See
'Capnography' above.)

● Cardiovascular monitoring
 • The standard device for intraoperative noninvasive blood pressure monitoring is the
automated office blood pressure monitor. The most common source of measurement
error is the use of an incorrectly sized cuff. The length of the cuff bladder should be 80
percent, and the width 46 percent of the circumference of the upper arm. Direct or
invasive blood pressure monitoring may be used for anesthesia for high-risk patients
and/or high-risk surgical procedures. (See 'Blood pressure' above.)

• A five lead electrocardiogram is preferred during anesthesia. Leads II and V5 are

usually monitored simultaneously to optimize detection of both rhythm and ischemia.
(See 'Electrocardiogram' above.)

• Pulmonary artery catheters, transesophageal echocardiography (TEE), and other

noninvasive hemodynamic monitors may be used to monitor cardiovascular function in
select patients. (See 'Other monitors of circulation' above.)

● Temperature monitoring – Patient temperature should be monitored during every

anesthetic. Core temperature should be monitored whenever possible, using
nasopharyngeal, distal esophageal, or less commonly tympanic membrane or pulmonary
artery probes. When using an axillary temperature probe, the probe should be placed over
the axillary artery with the arm kept at the patient’s side for the most accurate
measurement. (See 'Temperature monitoring sites' above.)

Use of UpToDate is subject to the Terms of Use.

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33. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in
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34. London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization
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39. Sessler DI. Perioperative thermoregulation and heat balance. Lancet 2016; 387:2655.
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41. Cork RC, Vaughan RW, Humphrey LS. Precision and accuracy of intraoperative temperature
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Topic 100067 Version 24.0
GRAPHICS

International anesthesia organizations' standards of monitoring during

anesthesia

Continuous
Organization Descriptor Patient monitors
presence of

ASA Qualified Minimum Inspired O 2 with low O 2 limit alarm

anesthesia Pulse oximeter, with audible pulse tone
personnel and low threshold alarm
Expired CO 2 continuous, with audible
alarm, during general anesthesia or
moderate/deep sedation
Disconnect alarm during mechanical
ventilation
Continuous ECG
Blood pressure and heart rate at least
every five minutes
During GA, pulse plethysmography or
oximetry, or continuous palpation of
pulse, or auscultation of heart sounds, or
monitored intraarterial pressure trace, or
ultrasound peripheral pulse
Temperature when clinically significant
changes in body temperature are
anticipated or suspected
AAGBI Anaesthetist of Minimum Pulse oximeter
appropriate NIBP
experience, or
ECG
fully trained
Capnography during GA and during
Physician
regional anesthesia or sedation whenever
Assistant
there is loss of patient response to verbal
(Anaesthesia)
contact
under the
Temperature before general anesthesia
supervision of a
Consultant and every 30 minutes during surgery

Anesthetist Should use Inspired volatile anesthetic agent if used

Inspired N 2 O if used
During GA:
Inspired and expired oxygen,
waveform capnography
During mechanical ventilation, airway
pressure, TV, and RR
If NMBAs used, quantitative
neuromuscular monitoring
throughout anesthesia
During TIVA with neuromuscular
blockade, processed EEG

Available Capillary blood glucose monitoring, blood

gas analysis, hemoglobin measurement,
flexible bronchoscopy

Additional Invasive blood pressure, cardiac output at

discretion of anaesthetist

EBA Appropriately Essential Pulse oximeter

trained and NIBP
experienced
ECG
anaesthesiologist
Airway gases: O 2 with audible alarm,
CO 2 , vapour when volatile anesthetics
used
Airway pressure

Available Peripheral nerve stimulator with NMBAs

Temperature
WHO-WFSA Vigilant Highly Audible signals and alarms
anesthesia recommended Pulse oximeter, including heart rate
professional (mandatory)
CO 2 detector for intubated patients
NIBP

Recommended Continuous monitoring with stethoscope

(precordial, pretracheal, or oesophageal)
Continuous capnography during GA or
deep sedation
Continuous ECG
Peripheral nerve stimulator with muscle
relaxants
Oxygen concentration monitoring,
including inspired concentration and
device to prevent delivery of hypoxic gas
mixture
Disconnect alarm during mechanical
ventilation
Intermittent temperature monitoring

Suggested Inspiratory and/or expired gas volumes,

and concentration of volatile agents
Invasive blood pressure in appropriate
cases
Continuous electronic temperature
monitoring in appropriate cases
Processed EEG in appropriate cases
Urine output in appropriate cases
CAS Physician or an Required Pulse oximeter
anesthesia BP (either invasive or non-invasive)
assistant (with
ECG
appropriate
Capnography for GA and sedation
training and
Agent-specific anesthetic gas analyser
experience)
with inhalation agents
under the
immediate Exclusively Temperature
supervision of an available for Peripheral nerve stimulator when NMBAs
anesthesiologist each patient used
Stethoscope (precordial, esophageal, or
paratracheal)
Lighting appropriate to visualize an
exposed portion of the patient

Immediately Spirometer
available Manometer to measure ETT cuff pressure
Equipment for invasive hemodynamic
monitoring (ie, intra-arterial, CVP)

Available Depth of anesthesia monitoring

equipment to be considered for use in
patients at increased risk for
intraoperative awareness
ANZCA Vigilant Mandatory Pulse oximeter
anaesthetist, CO 2 monitor during GA
practitioner,
ECG
medical
NIBP
practitioner
Inspired and end tidal concentration of
inhaled anesthetics when used
Temperature when warming devices used
Neuromuscular function monitor
(quantitative preferred) when considering
extubation after use of nondepolarizing
NMBAs

Available CO 2 monitor during sedation

Continuous invasive blood pressure
Temperature
Neuromuscular function monitor when
NMBAs used
Temperature
Other (EEG, CVP, CO, TEE, respiratory
mechanics) when clinically indicated

ASA: American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring.

Committee of Origin: Standards and Practice Parameters (Approved by the ASA House of
Delegates on October 21, 1986, last amended on October 20, 2010, and last affirmed on October
28, 2016). Available at
https://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-
guidelines/standards-for-basic-anesthetic-monitoring.pdf.
AAGBI: Association of Anaesthetists of Great Britain and Ireland. Available at
https://anaesthetists.org/Home/Resources-publications/Guidelines/Recommendations-for-
standards-of-monitoring-during-anaesthesia-and-recovery-2021.
EBA: European Board of Anaesthesiology. Available at http://www.eba-
uems.eu/resources/PDFS/safety-guidelines/EBA-Minimal-monitor.pdf.
WHO-WFSA: World Heath Organization - World Federation of Societies of Anaesthesiologists. Gelb
AW, Morriss WW, Johnson W, et al. World Health Organization-World Federation of Societies of
Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Can J
Anaesth 2018.
CAS: Canadian Anesthesiologists' Society. Available at
https://www.cas.ca/CASAssets/Documents/Practice-
Resources/Guidelines/Dobson2021_Article_GuidelinesToThePracticeOfAnest_1.pdf.
ANZCA: Australian and New Zealand College of Anaesthetists. Available at
https://www.anzca.edu.au/getattachment/0c2d9717-fa82-4507-a3d6-3533d8fa844d/PS18-
Guideline-on-monitoring-during-anaesthesia.
O 2 : oxygen; CO 2 : carbon dioxide; ECG: electrocardiogram; GA: general anesthesia; NIBP: non-
invasive blood pressure; N 2 O: nitrous oxide; NMBAs: neuromuscular blocking agents; EEG:
electroencephalogram; TIVA: total intravenous anesthesia; HR: heart rate; ETT: endotracheal tube;
CVP: central venous pressure; CO: cardiac output; TEE: transesophageal echocardiography.

Graphic 114602 Version 6.0

Basic monitoring during anesthesia

Primary physiologic
Monitoring Derived Addition
process/parameter Principle
equipment information functio
targeted

Oxygenation Inspired gas O 2 analyzer Paramagnetic Inspired/expired A low-level ala

O 2 content (with a low- sensor, fuel O 2 concentration automatically
limit alarm in (galvanic) cell, when placed activated by tu
use) polarographic downstream from on the anesth
(Clark) electrode, fresh flow control machine
mass valves
spectroscopy, or
Raman scattering

Blood Pulse The Beer-Lambert Hemoglobin Continuous

oxygenation oximeter law applied to saturation, pulse evaluation of
tissues and rate, relative pulse circulation, va
pulsatile blood amplitude pitch pulse to
flow. The relative displayed on and audible lo
absorbency at plethysmography threshold alar
wavelengths of waveform
660 and 940 nm is
used to estimate
saturation, which
is derived from
the ratio of
oxyhemoglobin to
the sum of
oxyhemoglobin
plus
deoxyhemoglobin.
Ventilation Exhaled Capnograph CO 2 molecules ETCO 2 , inspired Instantaneous
CO 2 absorb infrared CO 2 , diagnostic information a
radiation at 4.26 waveforms, Perfusion (
micrometers, respiratory rate, effectively
proportionate to apnea detection being
the CO 2 transporte
concentration through th
present in the vascular sy
breath sample Metabolism
effectively
being prod
by cellular
metabolism
Confirmati
tracheal tu
placement
intubation

Integrity of Disconnection Detects the Alarms if a Alarms if high

ventilation alarm cyclical changes in significant decrease pressures are
system airway pressure in in rate or pressure sensed
during the normal range occurs
mechanical
ventilation

Pulmonary Pulmonary Volume of gas Inspired and Pressure volu

mechanics flow and proportional to a expired volume, and flow volu
(volume, pressure drum movement, flow, and airway loops
flow, sensors changes in pressure
pressure) differential
pressure (near the
Y-connector) or in
electrical
resistance (hot
wire housed in a
monitor or
ventilator)
 Circulation Cardiac ECG The ECG monitor Heart rate and ST segment
activity detects, amplifies, rhythm depression/el
displays, and and trend ove
records the ECG with an audib
signal. alarm warning
significant
arrhythmias o
asystole

Arterial BP Noninvasive Oscillometric Arterial BP Indicator of o

BP monitor devices perfusion
automatically
inflate and deflate
the cuff, and have
electronic
pressure sensors
that record the
pressure
oscillations of the
arteries. The
pressure at which
maximal
oscillations occur
as the cuff is
deflated
corresponds with
MAP. Proprietary
algorithms are
used to calculate
systolic and
diastolic BP.

Temperature Temperature Devices with a Core or peripheral A greater than

monitor semiconductor, temperature core-to-periph
electrical temperature
resistance gradient is ind
decreases as of low cardiac
temperature output.
decreases

Temperature monitoring is conditional and can be waived according to the ASA document.

O 2 : oxygen; CO 2 : carbon dioxide; ETCO 2 : end-tidal carbon dioxide; ECG: electrocardiogram; BP:
blood pressure; MAP: mean arterial pressure.

Graphic 110080 Version 4.0

Oxygen and hemoglobin values at which central cyanosis occurs

The threshold for central cyanosis is a capillary reduced hemoglobin content of 5 g/dL, which can occur at
varying values of the two parameters that are measured most commonly, arterial oxygen saturation (SaO 2 )
and arterial hemoglobin content. The vertical axis shows values for venous, capillary, and arterial reduced
hemoglobin (RHB, g/dL blood), and the horizontal axis shows a percent saturation of hemoglobin in arterial
blood (SaO 2 ) along with corresponding PaO 2 (mmHg). Each diagonal line represents a different hemoglobin
content (g/dL). For example, central cyanosis can manifest when SaO 2 is 79% in a patient with a hemoglobin
of 15 g/dL.

Original figure modified for this publication. Reproduced from: Martin L, Khalil H. How much reduced hemoglobin is necessary to
generate central cyanosis? Chest 1990; 97:182. Illustration used with the permission of Elsevier Inc. All rights reserved.

Graphic 114333 Version 1.0

Causes and troubleshooting erroneous pulse oximetry readings

Problem and potential errors Solution

Inadequate waveform

Malposition of probe Reposition probe, alternate site

Motion artifact Reposition probe, alternate site

Hypoperfusion Reposition probe, alternate site, warming

Hypothermia Use ear or forehead probe, warming

Skin pigment Measure ABG

Falsely normal or elevated oximetry reading

Carboxyhemoglobin (eg, carbon monoxide Co-oximetry

poisoning)

High levels of glycohemoglobin A1c Measure ABG

metHb, sulfHb* Multiwavelength co-oximetry (metHb),

biochemical analysis (sulfHb)

Ambient light Remove ambient light source

Skin pigment Measure ABG

Falsely low oximetry reading

Inadequate waveform Reposition probe, alternate site

metHb* Multiwavelength co-oximetry

sulfHb* Biochemical analysis

HbS and inherited forms of abnormal Hb Measure HbS and abnormal Hb levels

Severe anemia Measure ABG

Venous pulsations or congestion Loosen probe, reposition patient or probe,

measure ABG

Ambient light Remove ambient light source

Nail polish Remove polish or change site

Vital dyes Usually transient, measure ABG

ABG: arterial blood gas; metHb: methemoglobin; sulfHb: sulfhemoglobin; HbS: sickle hemoglobin;
Hb: hemoglobin; SpO 2 : peripheral arterial oxygen saturation; SaO 2 : true arterial oxygen saturation.
* In these conditions, SpO 2 is low; when levels of metHb or sulfHb are mildly elevated, SpO 2
underestimates the SaO 2 , but when levels are high, the SpO 2 automatically trends towards 85%
such that pulse oximetry can overestimate SaO 2 .

Adapted from: Chan ED, Chan MM, Chan MM. Pulse oximetry: understanding its basic principles facilitates appreciation of its
limitations. Respir Med 2013; 107:789.

Graphic 107546 Version 4.0

Pulse oximeter waveform

Common pulsatile signals on a pulse oximeter.

(A) Normal signal showing the sharp waveform with a clear dicrotic
notch.

(B) Pulsatile signal during low perfusion showing a typical sine wave.

(C) Pulsatile signal with superimposed noise artifact giving a jagged

appearance.

(D) Pulsatile signal during motion artifact showing an erratic

waveform.

From: Jubran A. Pulse oximetry. Crit Care 2015; 19:272. Copyright © Jubran 2015.
Reproduced under the terms of the Creative Commons Attribution License (CC BY 4.0).
Available at: http://ccforum.biomedcentral.com/articles/10.1186/s13054-015-0984-8
(Accessed on May 17, 2016).

Graphic 107547 Version 1.0

Normal CO2 waveform

A - B: Dead space ventilation

B - C: Ascending expiratory phase

C - D: Alveolar Plateau

D: End-tidal CO 2

D - E: Descending inspiratory phase

Reproduced with permission from: Krauss B, Deykin A, Lam A, et al. Capnogram

shape in obstructive lung disease. Anesth Analg 2005; 100:884. Copyright © 2005
Lippincott Williams & Wilkins.

Graphic 67700 Version 11.0

Normal and abnormal capnograms

This graphic shows normal and abnormal capnograms, as follows:

A. Normal capnogram during positive pressure ventilation

B. Normal capnogram during spontaneous ventilation

C. Upsloping plateau that might occur with bronchospasm or a

kinked or obstructed endotracheal tube
D. Notched plateau caused by attempts at spontaneous ventilation
during controlled mechanical ventilation

E. Progressive decrease and disappearance of capnogram during

esophageal intubation

F. Rebreathing of carbon dioxide

G. Abrupt shortening of plateau phase, as might occur with

ruptured endotracheal tube cuff

Graphic 114177 Version 1.0

Capnogram with upsloping plateau

In patients with obstructive lung disease and an upsloping end tidal CO 2

plateau, inspiration may occur before the true end of expiration, and result in
a falsely low ETCO 2 (solid line). Reducing the respiratory rate (or briefly
stopping the ventilator) should allow full exhalation and an accurate ETCO 2
reading (dashed line).

Graphic 112619 Version 1.0

Contributor Disclosures
Gabriella Iohom, MD, PhD No relevant financial relationship(s) with ineligible companies to
disclose. Girish P Joshi, MB, BS, MD, FFARCSI Consultant/Advisory Boards: Baxter [anesthesia]. All of the
relevant financial relationships listed have been mitigated. Marianna Crowley, MD No relevant financial
relationship(s) with ineligible companies to disclose.

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