An Educational Intervention to Improve Comfort with Applying and Interpreting Transcutaneous CO2 and End-tidal CO2 Monitoring in the PACU.

PURPOSE: The purpose of this study was to assess the effectiveness of an educational program about measuring ventilation using devices that assess carbon dioxide levels in patients recovering from a surgical procedure. DESIGN: A pre-post survey of knowledge attainment from an educational intervention about measuring ventilation using end-tidal carbon dioxide (EtCO2) and transcutaneous carbon dioxide (tcPCO2) devices in the postanesthesia care unit (PACU) was distributed to current members of the American Society of PeriAnesthesia Nurses. METHODS: Participants received a 12-question pre-intervention (five were related to demographics) and a five-question post-intervention survey. Non-demographic survey questions used a one to five Likert scale to assess comfortability or confidence. The intervention created was a voice-over presentation designed to improve PACU RN's comfort and confidence with using and interpreting tcPCO2 or EtCO2 in the PACU. FINDINGS: PACU RNs (N = 108) reported they 'never' or 'rarely' used EtCO2 (n = 57, 52.7%) monitoring or tcPCO2 (n = 93, 86.1%) monitoring in the PACU. A paired t test revealed statistically significant differences in the PACU RN's pre-survey and posttest comfortability of applying and interpreting EtCO2 or tcPCO2 monitors (P < .05). CONCLUSIONS: Capnography monitoring should be considered a standard of care for PACU patients. Education of registered nurses working in the PACU is critical before implementing EtCO2 or tcPCO2 monitoring.

Identifying Patients Experiencing Opioid-Induced Respiratory Depression During Recovery From Anesthesia: The Application of Electronic Monitoring Devices.

BACKGROUND: Postsurgical patients experiencing opioid-related adverse drug events have 55% longer hospital stays, 47% higher costs associated with their care, 36% increased risk of 30-day readmission, and 3.4 times higher risk of inpatient mortality compared to those with no opioid-related adverse drug events. Most of the adverse events are preventable. GENERAL AIM: This study explored three types of electronic monitoring devices (pulse oximetry, capnography, and minute ventilation [MV]) to determine which were more effective at identifying the patient experiencing respiratory compromise and, further, to determine whether algorithms could be developed from the electronic monitoring data to aid in earlier detection of respiratory depression. MATERIALS AND METHODS: A study was performed in the postanesthesia care unit (PACU) in an inner city. Sixty patients were recruited in the preoperative admissions department on the day of their surgery. Forty-eight of the 60 patients wore three types of electronic monitoring devices while they were recovering from back, neck, hip, or knee surgery. Machine learning models were used for the analysis. RESULTS: Twenty-four of the 48 patients exhibited sustained signs of opioid-induced respiratory depression (OIRD). Although the SpO2 values did not change, end-tidal CO2 levels increased, and MV decreased, representing hypoventilation. A machine learning model was able to predict an OIRD event 10 min before the actual event occurred with 80% accuracy. LINKING EVIDENCE TO ACTION: Electronic monitoring devices are currently used as a tool to assess respiratory status using thresholds to distinguish when respiratory depression has occurred. This study introduces a potential paradigm shift from a reactive approach to a proactive approach that would identify a patient at high risk for OIRD. Capnography and MV were found to be effective tools in detecting respiratory compromise in the PACU.

Low-Dose Vasopressin and Analogues to Treat Intraoperative Refractory Hypotension in Patients Prescribed Angiotensin-Converting Enzyme Inhibitors Undergoing General Anesthesia: A Systematic Review.

This review assessed the utility of vasopressin and vasopressin analogues for the treatment of refractory hypotension associated with angiotensin-converting enzyme (ACE) inhibitors in the perioperative setting. A systematic review of the literature was conducted using MEDLINE, Embase, and ProQuest. Six randomized controlled trials met eligibility criteria. In the perioperative setting, continued use of ACE inhibitors within 24 hours before surgery remains controversial. Authors of the reviewed studies suggested that the morning dose of the ACE inhibitor be held, and those patients experienced decreased catecholamine use postoperatively and shorter duration of decreased mean arterial pressure. No incidence of refractory hypertension from withholding the morning dose of the ACE inhibitor was mentioned. All of the patients receiving vasopressin demonstrated improved hemodynamic stability with small, intermittent doses, without profound ischemic changes. For management (prevention and treatment) of ACE inhibitor-associated hypotension in the perioperative setting, all studies showed statistically significant success with vasopressin or vasopressin analogues for improvement of systemic blood pressures. Before vasopressin is widely accepted as a standard of care, further studies are needed to confirm these findings and assess the general utility of vasopressin in surgical populations for management of ACE inhibitor-associated refractory hypotension.