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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


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.



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



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



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



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.



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.



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



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



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



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



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.


The Next Step. . .


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


The Next Step. . .


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


The Next Step. . .


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


The Next Step. . .


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!”


The Next Step. . .


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. . .


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



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