07 capnography trends in procedural sedation
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Transcript of 07 capnography trends in procedural sedation
Capnography Trends in
Procedural Sedation
Capnography Trends in
Procedural Sedation
Jim Fielder, RRT-NPSClinical Specialist
Overlake Hospital Medical Center
Jim Fielder, RRT-NPSClinical Specialist
Overlake Hospital Medical Center
Procedural Sedation
Procedural Sedation
The new Conscious Sedation
The oxymoron is gone!
The new Conscious Sedation
The oxymoron is gone!
Procedural Sedation
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.
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.
The Procedures
The Procedures Cardioversion
Thoracentesis Thoracotomy/chest tube placement Central catheter placement Transesophageal Echocardography Orthopedic/fracture reductions Dislocation reductions Endoscopy ERCP
Cardioversion Thoracentesis Thoracotomy/chest tube placement Central catheter placement Transesophageal Echocardography Orthopedic/fracture reductions Dislocation reductions Endoscopy ERCP
The Procedures continued:
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. . . .
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. . . .
Procedural Sedation
Procedural Sedation And everyday patients are put at
risk: Oversedation At risk patients:
OSA Undiagnosed cardiac issues Hypersensitivity to sedation drugs Etc, etc.
And everyday patients are put at risk: Oversedation At risk patients:
OSA Undiagnosed cardiac issues Hypersensitivity to sedation drugs Etc, etc.
Procedural Sedation
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!
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!
Our Path Today. . . 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
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
Procedural Sedation
Procedural Sedation Oximetery appeared in the 1980’s
It quickly became the 5th Vital Sign
It became the next best thing to . . .
Oximetery appeared in the 1980’s
It quickly became the 5th Vital Sign
It became the next best thing to . . .
Canned BeerCanned Beer
OximetryOximetry Gained overnight popularity
By 1987, the standard of care for the administration of a general anesthetic in the US included pulse oximetry
Gained overnight popularity
By 1987, the standard of care for the administration of a general anesthetic in the US included pulse oximetry
OximetryOximetry 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.”
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.”
OximetryOximetry Has since fallen from grace
It has been observed to be the great cover-up “number”
Has since fallen from grace
It has been observed to be the great cover-up “number”
Capnography Emerges
Capnography Emerges
CONCLUSIONS: Abnormal ETCO2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO2 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
CONCLUSIONS: Abnormal ETCO2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO2 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
Capnography Emerges
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
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
Capnography Emerges
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
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
Capnography Emerges
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
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
Capnography Emerges
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
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
Overlake Hospital’s Road
Overlake Hospital’s Road
2005 New Procedural Sedation Guidelines were drawn up by a multidisciplinary committee
SpO2 and a Respiratory Care Practitioner were initially recommended to provide monitoring at every Procedural Sedation to be done at Overlake.
2005 New Procedural Sedation Guidelines were drawn up by a multidisciplinary committee
SpO2 and a Respiratory Care Practitioner were initially recommended to provide monitoring at every Procedural Sedation to be done at Overlake.
Overlake Hospital’s Road
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
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
Overlake Hospital’s Road
Overlake Hospital’s Road
Solutions to explore: Explore possibility of ETCO2 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
Solutions to explore: Explore possibility of ETCO2 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
Overlake Hospital’s Road
Overlake Hospital’s Road
Explore possibility of ETCO2 monitoring Respiratory Care was charged to find an
appropriate ETCO2 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
Explore possibility of ETCO2 monitoring Respiratory Care was charged to find an
appropriate ETCO2 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
Overlake Hospital’s Road
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 ETCO2 monitoring, current and future planned monitoring systems and ability to operate as a stand-alone device.
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 ETCO2 monitoring, current and future planned monitoring systems and ability to operate as a stand-alone device.
Overlake Hospital’s Road
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.
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.
Overlake Hospital’s Road
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
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
Overlake Hospital’s Road
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
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
Overlake Hospital’s Road
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
Capital purchase requests were filled and the items purchased:
$24,000 for 8 Capnography units
$3,000 for disposables per month
Overlake Hospital’s Road
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
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
Overlake Hospital’s Road
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.
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.
Overlake Hospital’s Road
The Next Step. . .
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 ETCO2
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
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 ETCO2
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
Overlake Hospital’s Road
The Next Step. . .
Overlake Hospital’s Road
The Next Step. . . Respiratory Care Pre-Procedure Assessment Tool 1 year of testing and evaluation
All individuals were to have ETCO2 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
Respiratory Care Pre-Procedure Assessment Tool 1 year of testing and evaluation
All individuals were to have ETCO2 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
Overlake Hospital’s Road
The Next Step. . .
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
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
Overlake Hospital’s Road
The Next Step. . .
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!”
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!”
Overlake Hospital’s Road
The Next Step. . .
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
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
Procedural SedationWe must remember. . .
Procedural SedationWe 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
Our patients and their safety is in our hands:
We must screen
We must monitor
We must have procedures in place to protect
Procedural SedationWe must remember. . .
Procedural SedationWe must remember. . .
Job one is this:We must be prudent in our
sedation and zealous in our monitoring!
Job one is this:We must be prudent in our
sedation and zealous in our monitoring!
Thank You
Thank You www.rcsw.org