Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis.

End-tidal CO2 has been advocated to improve safety of emergency department (ED) procedural sedation by decreasing hypoxia and catastrophic outcomes. This study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO2 monitoring for ED procedural sedation in prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Estimates for efficacy of capnography and safety of sedation were derived from the literature. This model was then applied to all procedural sedations performed in US EDs with assumptions selected to maximize efficacy and minimize cost of implementation. Assuming that capnography decreases the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per 5 years). Over a 5-year period, implementing routine end-tidal CO2 monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted life-year. Sensitivity analyses suggest that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO2 monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.

Sondaje naso/orogástrico en el paciente pediátrico. Revisión de métodos de comprobación de la ubicación / Naso-orogastric tube in paediatric patients. Review of methods of confirmation of placement

La colocación de la sonda gástrica (SG) es un procedimiento no infrecuente en la población pediátrica. Las SG se utilizan con asiduidad en los servicios de Hospitalización, de Urgencias Pediátricas y en los de Cuidados Críticos. Sus objetivos son diagnósticos, terapéuticos y la descompresión y evacuación del contenido aspirado. La colocación a ciegas de la SG conlleva tasas de colocación incorrecta de entre un 4.7 % y un 69 % de los casos. Se necesita por lo tanto la utilización de un método fiable de determinación de la colocación de la misma. La radiografía (Rx) de tórax es el único método fiable al cien por cien (gold standard), pero solo confirma la colocación en el momento exacto de realización de la Rx. Los métodos no radiológicos son una alternativa fiable que contribuyen a reducir la exposición a radiaciones en los pacientes pediátricos. Hay diversos métodos alternativos a la Rx para verificar la colocación apropiada de la SG y que están respaldados por distintos grados de evidencia científica. Algunos son: medida de la sonda desde el punto de entrada; auscultación, aspiración del contenido estomacal o intestinal para inspeccionarlo visualmente; medición del pH; capnografía, o la combinación de varios de estos métodos. En este artículo se revisa a fondo la validez y la seguridad de algunos de estos métodos no radiológicos como métodos de comprobación de la ubicación de la SG (AU)

Nasogastric tube (NGT) placement is a frequent procedure in the paediatric population. Nasogastric and orogastric tubes are commonly used in hospitalized children, in the paediatric emergency departments and in critical care departments. They have diagnostic, therapeutic, descompression or evacuation of gastric aspirates objectives. Making a blind placement of nasogastric tubes, involve that nasogastric tube could be misplaced in 4.7 % to 69 % of cases. An accurate method for confirmation of nasogastric tube positioning is therefore needed. Chest X-ray remains the only hundred per cent reliable method (gold standard), but it only confirms tube positioning at the exact time of the X-ray. Non-radiologic verification methods provide an accurate alternative and contribute to decrease radiation exposure for pediatric patients. Non-radiologic methods to verify appropiate placement of tubes are many and are supported by different degrees of evidence in the literature: measurement of tube length from point of entry; auscultation; placing the tube in water to assess bubbling; aspiration of stomach or intestinal contents for visual inspection; pH testing; use of CO2 monitoring devices, or combinations of these methods. In this article we thoroughly review the reliability and safety of these non radiologic methods for the verification of nasogastric tube placement (AU)

The role of capnography in endoscopy patients undergoing nurse-administered propofol sedation: a randomized study.

OBJECTIVE. Standard benzodiazepine/opioid cocktail has proven inferior to propofol sedation during complicated endoscopic procedures and in low-tolerance patients. Propofol is a short-acting hypnotic with a potential risk of respiratory depression at levels of moderate to deep sedation. The existing literature on capnography for endoscopy patients sedated with nurse-administered propofol sedation (NAPS) is limited. Can the addition of capnography to standard monitoring during endoscopy with NAPS reduce the number, duration, and level of hypoxia. MATERIALS AND METHODS. This study was a randomized controlled trial with an intervention group (capnography) and a control group (without capnography). Eligible subjects were consecutive patients for endoscopy at Gentofte Hospital compliant with the criteria of NAPS. RESULTS. Five hundred and forty patients, 263 with capnography and 277 without capnography, were included in the analysis. The number and total duration of hypoxia was reduced by 39.3% and 21.1% in the intervention group compared to the control group (p > 0.05). No differences in actions taken against insufficient respiration were found. Changes in end-tidal carbon dioxide (R = 0.177, p-value < 0.001) and respiratory rate (R = 0.092, p-value < 0.001) were correlated to oxygen saturation (SpO2) up to 36 s prior to changes in SpO2. CONCLUSIONS. Capnography seems to reduce the number and duration of hypoxia in NAPS patients (p > 0.05). Capnography is able to detect insufficient respiration that may lead to hypoxia prior to changes in pulse oximetry. However, due to a limited clinical benefit and additional costs associated with capnography, we do not find capnography necessary during the use of NAPS.

La capnografía en los servicios de emergencia médica / Capnography in the emergency medical services

La capnografía es una monitorización no invasiva complementaria a la pulsioximetría, ya que esta valora la oxigenación, y mediante la capnografía se analiza la ventilación del paciente, midiendo el dióxido de carbono exhalado. Además, puede valorar la perfusión y el metabolismo del paciente en algunos casos. La capnografía se emplea desde hace más de 30 años para monitorizar al paciente intubado en el quirófano, donde es estándar de atención. El avance tecnológico ha permitido desarrollar capnógrafos portátiles fáciles de usar que ofrecen lecturas precisas tanto en pacientes intubados como con ventilación espontánea. Estos capnógrafos se están empezando a emplear en los servicios de emergencia médica (SEM) de España en los últimos años. La presente revisión bibliográfica ofrece una visión actual de la capnografía para colaborar en la formación de los profesionales sanitarios en esta monitorización de la ventilación que se encuentra en pleno surgimiento en los SEM españoles (AU)

Capnography is a non-invasive monitoring technique used in conjunction with pulse oximetry since the latter measures oxygenation whereas capnography is used to assess the patient¿s ventilation by measuring exhaled carbon dioxide. In some cases, it can also be used to measure the patient¿s perfusion and metabolism. Capnography has been used for over 30 years to monitor intubated patients during surgery where it is seen as a standard of care. Technological advances have led to the development of easy-to-use, portable capnographs that provide accurate readings both for intubated and spontaneously breathing patients. Over recent years, Emergency Medical Services (EMS) in Spain have begun using these capnographs. This bibliographical review offers a current overview of capnography that can be used to train healthcare professionals in the use of this ventilation monitoring technique, which is rapidly emerging in Spanish EMS (AU)

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Testing nasogastric tube positioning in the critically ill: exploring the evidence.

Nutritional support in the critically ill is commonly delivered via a nasogastric tube. Correct positioning in the stomach must first be confirmed as inadvertent feeding into the lungs carries a high risk of mortality. The National Patient Safety Agency (2005) recommends the method of pH testing nasogastric tube aspirates to verify tube position. This article critically analyses the research supporting this method, and questions its reliability in critically ill patients whose gastric pH may well be altered due to prophylactic stress ulcer medications and continuous feeding regimens. There is a lack of quality research testing this method in the critically ill population. The theory-practice gap is addressed, and preliminary research behind use of techniques such as capnography and capnometry is also examined.

End-tidal carbon dioxide monitoring: a VITAL sign worth watching.

Capnography is the monitoring of end-tidal carbon dioxide in waveform and numeric display. For this technology to be useful, the critical care nurse must have a clear understanding of the normal capnography waveform and what the alterations in this waveform represent. The critical care nurse can use this information to plan patient care interventions with other critical care team members and to adjust care based on the patient's response. End-tidal carbon dioxide physiology, normal waveforms, abnormal waveforms, and clinical aspects of capnography monitoring are included.

Capnography in the gastroenterology lab.

This article provides the reader with information and education regarding the use of capnography for both adult and pediatric patients undergoing procedural sedation during endoscopy by: reviewing the basics of capnography, in addition to the physiology of ventilation and oxygenation; illustrating how capnography may provide an earlier warning of hypoxemia than does pulse oximetry; briefly discussing current guidelines for procedural sedation and the potential role of capnography; and reviewing clinical situations causing changes in the capnogram waveforms and the nursing interventions that should be made in response to such changes.

Monitoring carbon dioxide in critical care: the newest vital sign?

Carbon dioxide (CO(2)) monitoring can yield substantial information about cardiac and pulmonary function. Because capnography is not complicated, it is relatively easy to apply in a wide variety of clinical settings. A new area of CO(2) measurement is sublingual CO(2). Although outcomes data are as yet unavailable for this technology, its ease of use makes it an attractive monitoring tool to assess severity of illness and predict patients' responses to therapy. This article describes the pathophysiology and clinical applications of the technologies and describes why they may well be "the newest vital signs."

Capnography application in acute and critical care.

The use of capnography has expanded over recent years. Currently, capnography is used in a variety of acute care settings. This article describes what capnography is and how it is used. The normal and abnormal capnogram or waveforms are described to assist in identifying various clinical situations. The multiplicity of clinical indications include detection of pulmonary embolism as well as malpositioned endotracheal/tracheal, gastric, and small bowel tubes. Capnography also provides clinicians with information regarding expiratory breathing patterns and assists in perfusion assessments such as those for cardiopulmonary resuscitation. Finally, case studies are provided to help the reader apply the concepts of capnography to a variety of acute care settings.

Regional carbon dioxide monitoring: a different look at tissue perfusion.

Adequate tissue oxygenation is one of the main therapeutic goals for the critically ill patient. Until recently, the perfusion status of the critically ill and injured has been assessed by global indices such as blood pressure, heart rate, and urine output. However, these global parameters are inadequate in that they fail to demonstrate the actual perfusion status of a patient. Research has shown the splanchnic region to be a pivotal organ bed in response to shock. Because this region shows early signs of hypoperfusion and hypoxia, its monitoring provides for more effective and complete resuscitation. To that end, gastric tonometry offers a noninvasive means by which early symptoms of low flow can be determined, allowing for optimization of tissue perfusion and patient outcome. The most proximal segment of the gastrointestinal tract offers promising information regarding tissue perfusion with the use of sublingual capnography.

Sublingual capnometry: an alternative to gastric tonometry for the management of shock resuscitation.

Normal vital signs do not reflect the physiologic aberrations after blood loss. Recognition of hypoperfusion during resuscitation can avoid the development of multiple organ failure. Advances in technology enable the clinician to monitor changes, potentially identifying tissue hypoxia much earlier than previously was possible. Gastric tonometry can be quite helpful in the intensive care unit in identifying gastric hypoperfusion, but has considerable drawbacks. The ability to monitor P(SI)CO(2) via sublingual capnometers overcomes some limitations of gastric tonometry and may be a valuable aid in the prehospital phase, the emergency department, and the intensive care unit in identifying end points of resuscitation.

Procedural sedation. Capnography's heightened role.

Outside the OR, it has become increasingly common for nurses to administer procedural sedation. Now, with capnography, you can monitor patients' respiratory status more closely and accurately.

Hemodynamic applications of capnography.

The measurement of the pressure of exhaled carbon dioxide (PetCO2) via capnography has several useful hemodynamic applications. This article discusses integrating PetCO2 values with hemodynamic assessment. Capnography can be applied to hemodynamic assessment in three key ways: (1) identification of end-expiration during pulmonary artery and central venous pressure measurements, (2) assessment of pulmonary perfusion and alveolar deadspace, (3) assessment of cardiopulmonary resuscitative efforts. The article presents research, sample waveforms for end-expiration identification, and case examples.