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07 capnography trends in procedural sedation


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  • 1. Capnography Trends in Procedural Sedation Jim Fielder, RRT-NPS Clinical Specialist Overlake Hospital Medical Center
  • 2. Procedural Sedation
    • The new Conscious Sedation
    • The oxymoron is gone!
  • 3. Procedural Sedation
    • Procedural sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis(reduce anxiety) during a potentially painful or frightening procedure.
  • 4. The Procedures
    • Cardioversion
    • Thoracentesis
    • Thoracotomy/chest tube placement
    • Central catheter placement
    • Transesophageal Echocardography
    • Orthopedic/fracture reductions
    • Dislocation reductions
    • Endoscopy
    • ERCP
  • 5. The Procedures continued:
    • Percutaneous Tracheotomy
    • Major dental procedures
    • Laceration repair in both pediatrics and adults
    • Bone marrow aspiration
    • Burn or wound debridement
    • Cardiac catheterization
    • Interventional radiology procedures
    • Circumcision
    • And the list goes on. . . .
  • 6. Procedural Sedation
    • And everyday patients are put at risk:
      • Oversedation
      • At risk patients:
        • OSA
        • Undiagnosed cardiac issues
        • Hypersensitivity to sedation drugs
        • Etc, etc.
  • 7. Procedural Sedation
    • These patients and their safety are in our hands
      • We must screen
      • We must monitor
      • We must have procedures in place to protect
      • We must be prudent in our sedation and zealous in our monitoring!
  • 8. Our Path Today. . .
    • What we’ve monitored in the past
    • Where the “organizations” are currently headed for monitoring during Procedural Sedation
    • The process Overlake Hospital took to put in place Capnography as our “Gold Standard” for monitoring in Procedural Sedation
  • 9. Procedural Sedation
    • Oximetery appeared in the 1980’s
      • It quickly became the 5th Vital Sign
      • It became the next best thing to . . .
  • 10. Canned Beer
  • 11. Oximetry
    • Gained overnight popularity
    • By 1987, the standard of care for the administration of a general anesthetic in the US included pulse oximetry
  • 12. Oximetry
    • In 1988, a legal brief for CRNA’s stated:
      • “ . . .if you are a CRNA administering anesthesia without a pulse oximeter, I would urge you to prepare now to defend your practice.”
  • 13. Oximetry
    • Has since fallen from grace
    • It has been observed to be the great cover-up “number”
  • 14. Capnography Emerges
    • CONCLUSIONS: Abnormal ETCO 2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO 2 abnormalities that occurred before oxygen desaturation or observed hypoventilation.
    • Acad Emer Med, 2006 May
      • Burton JH, Harrah JD, Germann CA, Dillion DC. Department of Emergency Medicine, Maine Medical Center, Portland, ME, US
  • 15. Capnography Emerges
      • CONCLUSIONS: The results of this controlled effectiveness trial support routine use of microstream capnography to detect alveolar hypoventilation and reduce hypoxemia during procedural sedation in children. In addition, capnography allowed early detection of arterial oxygen desaturation because of alveolar hypoventilation in the presence of supplemental oxygen. The current standard of care for monitoring all patients receiving sedation relies overtly on pulse oximetry, which does not measure ventilation.
      • Pediatrics , 2006 Jun
        • Lightdale JR, Goldman DA, Feldman HA, Newburg AR, Dinardo JA, Fox VL. Children's Hospital Boston, Boston, Massachusetts, USA
  • 16. Capnography Emerges
      • CONCLUSION: When propofol is administered for ED deep sedation to facilitate pediatric orthopedic reduction, continuous capnography detects most airway and respiratory events leading to intervention before clinical examination or pulse oximetry.
      • Ann Emerg Med 2007 Jan
        • Anderson JL, Junkins E, Pribble C, Guenther. Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA
  • 17. Capnography Emerges
    • In the 1990’s Anesthesia came onboard and identified Capnography as a standard
    • Numerous articles, studies show Capnography catches what Oximetry can hide
    Capnography Tracing Oximetery Tracing
  • 18. Capnography Emerges
    • Other Professional Societies have come alongside Anesthesia and have adopted Capnography and made it a new standard of care/monitoring
      • Gastroenterology
      • Emergency Medicine
      • Orthopedics
      • Critical Care
      • Pediatrics
  • 19. Overlake Hospital’s Road
    • 2005 New Procedural Sedation Guidelines were drawn up by a multidisciplinary committee
    • SpO 2 and a Respiratory Care Practitioner were initially recommended to provide monitoring at every Procedural Sedation to be done at Overlake.
  • 20.  
  • 21. Overlake Hospital’s Road
    • That’s a scary thought!
    • Respiratory Care would need a 6.5 additional FTE’s. for day and evening shift coverage, 7 days week to provide coverage of all our concurrent procedural sedations
      • Problems
        • FTE costs - $400,000 for the first year
        • Increased turn-over due to repeated, non-active, interventions leading to boredom
  • 22. Overlake Hospital’s Road
    • Solutions to explore:
      • Explore possibility of ETCO 2 monitoring
      • Reserve RCP presence for the highest risk, time intensive cases
      • Develop a Pre-Procedure Respiratory Assessment Tool to help identify those patients at the greatest risk for need of intervention
  • 23. Overlake Hospital’s Road
    • Explore possibility of ETCO 2 monitoring
      • Respiratory Care was charged to find an appropriate ETCO 2 monitor that could be used throughout the hospital
        • Goals
          • Be compatible with current and future technology
          • Have one source disposables that are compatible in all areas
          • Provide alarms, waveforms, and numeric data
          • Proven product
            • Leading edge not bleeding edge
  • 24. Overlake Hospital’s Road
    • Several devices reviewed along with disposables and ability to interface.
    • Cost analysis of both capital and disposable costs were done
    • One product allowed us compatibility to function with current defibrillators with ETCO 2 monitoring, current and future planned monitoring systems and ability to operate as a stand-alone device.
  • 25. Overlake Hospital’s Road
    • That Product was:
      • Oridion Microcap
        • This same technology was OEM’s
        • and already in our several defibrillators
          • Allowed same disposables on all units
        • This same technology was compatible with our monitoring systems currently in place and continued with plans for technology upgrades in 2007 when our new tower opened.
  • 26. Overlake Hospital’s Road
    • Oridion Microstream
      • The Oridion Microstream uses a disposable technology that allows consistent results from both a cannula/clamshell or cannula/biteblock devices.
      • These same devices worked on current technology
  • 27. Overlake Hospital’s Road
    • Areas where the devices would reside determined
      • Critical Care
      • Special Procedures Unit
      • Emergency Dept
      • Cardiology EP Lab
      • IR
    • Capital purchase requests were filled and the items purchased
  • 28. Overlake Hospital’s Road
    • Capital purchase requests were filled and the items purchased:
      • $24,000 for 8 Capnography units
      • $3,000 for disposables per month
  • 29. Overlake Hospital’s Road
    • SuperUsers were determined and given training and hands-on time
    • Staff training sessions
    • Go-Live dates set
      • Company representatives were present to work alongside SuperUsers and staff
      • Respiratory Care staff - RCP’s became the troubleshooting resource group
  • 30. Overlake Hospital’s Road
      • ERCP - Endoscopy Retrograde Cholangiopancreatography
        • Respiratory Care Practitioners would be present to monitor patients for this specific procedure. Capnography would be a part of this monitoring.
      • Any time it was deemed necessary, Respiratory Care would and could be called to provide monitoring for other procedures. Capnography would be a part of all procedural sedation.
  • 31. Overlake Hospital’s Road The Next Step. . .
    • Respiratory Care has since developed a Pre-Procedure Assessment Tool
      • The tool classified our patients after a brief assessment:
          • Classifying our patients into one of 3 categories
            • #1 Patient is cleared to have ERCP with ETCO 2 monitoring, RCP will be on standby
            • #2 RCP will be present at ERCP
            • #3 Patient’s medical condition suggest Anesthesia be contacted for further evaluation
  • 32. Overlake Hospital’s Road The Next Step. . .
    • Respiratory Care Pre-Procedure Assessment Tool
      • 1 year of testing and evaluation
          • All individuals were to have ETCO 2 monitoring started and baseline established prior to onset of sedation
          • Results:
            • 85% of individuals screened can have procedure without RCP presence
            • 9% of individuals screened had RCP present
            • 6% of individuals screened were passed to Anesthesia
  • 33. Overlake Hospital’s Road The Next Step. . .
    • Pre-Procedure Assessment Tool
        • 85% of individuals screened can have procedure without RCP presence
          • 91% of these individuals required no intervention during their procedures
          • 9% required minimal intervention
          • Respiratory Care was never called to assist - moderate intervention
  • 34. Overlake Hospital’s Road The Next Step. . .
    • Pre-Procedure Assessment Tool
        • 9% of individuals screened can have procedure with a RCP presence
          • 60% of these individuals required no intervention during their procedures
          • 40% required intervention by the RCP who was present
        • The 6% - those individuals who we deemed should be seen by Anesthesia, Anesthesia reported “Good Call!”
  • 35. Overlake Hospital’s Road The Next Step. . .
    • Respiratory Care Pre-Procedure Assessment Tool
        • After one year of data with predictable results, RCP’s are no longer required to be in attendance of all ERCP procedures
  • 36. Procedural Sedation We must remember. . .
    • Our patients and their safety is in our hands:
      • We must screen
      • We must monitor
      • We must have procedures in place to protect
  • 37. Procedural Sedation We must remember. . .
    • Job one is this:
    • We must be prudent in our sedation and zealous in our monitoring!
  • 38. Thank You