Capnography and Depth of Sedation During Propofol Sedation in Children

Bias between capnometry and venous carbon dioxide during initial assessment of pediatric emergency department patients: A video-based study

Objective

The bias of capnometry (ETCO2) and venous carbon dioxide (vpCO2) among pediatric emergency department (PED) patients triaged to critical care areas is unknown. We aimed to explore correlations and bias between ETCO2 and vpCO2¸and identify predictors of bias.

Methods

This was an observational, video-based, retrospective study comparing ETCO2 and vpCO2. Pediatric patients with simultaneous ETCO2 and vpCO2 data were included. Our primary aim utilized linear regressions to determine correlations and Bland-Altman analysis to assess bias. Our secondary aim utilized multiple regression to identify clinical covariates contributing to bias. Covariates included age, respiratory rate, heart rate, mean arterial blood pressure, capnometry interface, PED diagnosis, and PED disposition.

Results

A total of 200 PED patients with ETCO2 and vpCO2 data were included. The median (interquartile range [IQR]) ETCO2, vpCO2, and ΔCO2 in mmHg were 38 (32, 46), 49 (41, 61), and 11 (4, 20), respectively. ETCO2 (r = 0.76) and ΔCO2 (r = 0.71) were highly correlated with vpCO2. The mean bias between ETCO2 and vpCO2 was -14.1 mmHg (95% confidence interval [CI], -41.9 -13.7). The bias between ETCO2 and vpCO2 increased at higher values of each measure. ETCO2 sampling interface was the only independent predictor of vpCO2 in our multivariate analysis. Patients requiring bag-valve mask (BVM) ventilation had the highest median bias between ETCO2 and vpCO2 (29 mmHg, IQR 15, 37).

Conclusion

ETCO2 and vpCO2 were highly correlated. However, bias increased at higher levels of both ETCO2 and vpCO2. Among PED patients, ETCO2's ability to approximate vpCO2 diminishes with worsening hypercarbic respiratory failure.

Impact of capnography on patient safety in high- and low-income settings: a scoping review

BACKGROUND

Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs.

METHODS

We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included.

RESULTS

The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes.

CONCLUSION

Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

The utility of the pretracheal stethoscope in detecting ventilatory abnormalities during propofol sedation in children

BACKGROUND

Monitoring of ventilation with capnography or a stethoscope is recommended because the detection of ventilatory abnormalities can be significantly delayed by the use of pulse oximetry alone in patients receiving supplemental oxygen. The aim of this study was to evaluate the diagnostic performance of the pretracheal stethoscope with pulse oximetry and capnography in detecting adverse respiratory events during propofol sedation in nonintubated children. We hypothesized that use of the pretracheal stethoscope would facilitate earlier detection of adverse respiratory events.

METHODS

This was a prospective observational study of children undergoing procedural sedation at a pediatric sedation program. A pretracheal stethoscope, pulse oximetry, and nasal capnography were attached at the discretion of the sedation nurse and provider to monitor ventilation.

RESULTS

We enrolled 104 patient encounters (mean recorded time, SD 8.3 ± 5.3 minutes) from February, 2015 to March, 2017. The pretracheal stethoscope was the first monitor to detect adverse events in 64% (25/39) of patients compared to 18% (7/39) for capnography and 15% (6/39) for pulse oximetry. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation. The positive predictive value for detecting a true ventilation abnormality and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 100% (90%-100%), 18% (10%-31%), and 27% (18%-38%), respectively. The negative predictive value and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 88% (82%-92%), 68% (59%-75%), and 70% (61%-78%), respectively. Limitations are short observation time, nonstandardized application of respiratory monitors, and too much focus on auscultation.

CONCLUSION

A pretracheal stethoscope in conjunction with capnography and pulse oximetry detects most sedation-related adverse events first. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation.

Procedural sedation and analgesia practices in the emergency centre

Introduction

Procedural sedation and analgesia allows the clinician to safely and efficiently administer sedation, analgesia, anxiolysis and sometimes amnesia to facilitate the performance of various procedures in the emergency centre. The aim of this study is to determine current sedation practices, common indications and major obstacles in selected emergency centres across Southern Gauteng, South Africa, with a view to improving future standards and practices.

Methods

This was a prospective, questionnaire based, cross-sectional interview of emergency centre managers or their designee of selected private-sector and public-sector hospitals in Southern Gauteng.

Results

Overall, 17 hospitals completed the interview, nine (53%) public-sector and eight (47%) private-sector hospitals, with 36% of hospitals being aligned to an academic institute. All hospitals performed procedural sedation in their emergency centre. Forty seven percent of managers had between ten and 19 years of clinical experience post internship. Although eleven (64.7%) managers achieved a postgraduate qualification in emergency medicine, only seven (41%) were accredited with a Fellowship of the College of Emergency Medicine (FCEM) qualification and only three (17.7%) centres employed three or more specialists. The majority of centres (52.3%) performed between ten and 30 procedures per month requiring sedation. Staff training in the practice of procedural sedation was mostly obtained internally (52.9%), from in-house seniors. Essential drugs, procedure monitors, resuscitation equipment and protocols were all available in 70.6% of centres.

Conclusion

Although the safe practice and awareness of procedural sedation and analgesia in both public-sector and private-sector emergency centres in Southern Gauteng appears to be on the increase, there is still a need to enhance practitioner training and promote awareness of current local and international trends, protocols and recommendations.

Capnography sensor use is associated with reduction of adverse outcomes during gastrointestinal endoscopic procedures with sedation administration

Background

Evidence to date suggests that capnography monitoring during gastrointestinal endoscopic procedures (GEP) reduces the incidence of hypoxemia, but the association of capnography monitoring with the incidence of other adverse outcomes surrounding these procedures has not been well studied. Our aims were to estimate the incidence of pharmacological rescue events and death at discharge from an inpatient or outpatient hospitalization where GEP was performed with sedation, and to determine if capnography monitoring was associated with reduced incidence of these adverse outcomes.

Methods

This retrospective Premier Database analysis included medical inpatients and all outpatients undergoing GEP with sedation. Patients were grouped as follows: (1) pulse oximetry (SpO₂) only, (2) capnography only, (3) SpO₂ with capnography, and (4) neither SpO₂ nor capnography. Multivariable logistic regression and propensity-score matching were used to compare patients with capnography sensor use to patients with only SpO₂ sensor use. Outcome measures included the incidence of pharmacological rescue events, as defined by administration of naloxone and/or flumazenil, and death.

Results

Two hundred fifty eight thousand and two hundred sixty two inpatients and 3,807,151 outpatients were analyzed. For inpatients, capnography monitoring was associated with a 47% estimated reduction in the odds of death at discharge (OR: 0.53 [95% CI: 0.40–0.70]; P < 0.0001) and a non-significant 10% estimated reduction in the odds of pharmacological rescue event at discharge (0.91 [0.65–1.3]; P = 0.5661). For outpatients, capnography monitoring was associated with a 61% estimated reduction in the odds of pharmacological rescue event at discharge (0.39 [0.29, 0.52]; P < 0.0001) and a non-significant 82% estimated reduction in the odds of death at discharge (0.18 [0.02, 1.99]; P = 0.16).

Conclusions

In hospital medical inpatients and all outpatients undergoing GEP performed with sedation, capnography monitoring was associated with a reduced likelihood of pharmacological rescue events in outpatients and death in inpatients when assessed at discharge. Despite the limitations of the retrospective data analysis methodology, the use of capnography during these procedures is recommended.

Electronic supplementary material

The online version of this article (10.1186/s12871-017-0453-9) contains supplementary material, which is available to authorized users.

Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations

BACKGROUND

Capnography has many uses in the emergency department (ED) and critical care setting, most commonly cardiac arrest and procedural sedation.

OBJECTIVE OF THE REVIEW

This review evaluates several indications concerning capnography beyond cardiac arrest and procedural sedation in the ED, as well as limitations and specific waveforms.

DISCUSSION

Capnography includes the noninvasive measurement of CO₂, providing information on ventilation, perfusion, and metabolism in intubated and spontaneously breathing patients. Since the 1990s, capnography has been utilized extensively for cardiac arrest and procedural sedation. Qualitative capnography includes a colorimetric device, changing color on the amount of CO₂ present. Quantitative capnography provides a numeric value (end-tidal CO₂), and capnography most commonly includes a waveform as a function of time. Conditions in which capnography is informative include cardiac arrest, procedural sedation, mechanically ventilated patients, and patients with metabolic acidemia. Patients with seizure, trauma, and respiratory conditions, such as pulmonary embolism and obstructive airway disease, can benefit from capnography, but further study is needed. Limitations include use of capnography in conditions with mixed pathophysiology, patients with low tidal volumes, and equipment malfunction. Capnography should be used in conjunction with clinical assessment.

CONCLUSIONS

Capnography demonstrates benefit in cardiac arrest, procedural sedation, mechanically ventilated patients, and patients with metabolic acidemia. Further study is required in patients with seizure, trauma, and respiratory conditions. It should only be used in conjunction with other patient factors and clinical assessment.

Capnography versus standard monitoring for emergency department procedural sedation and analgesia

BACKGROUND

Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting.

OBJECTIVES

To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015.

SELECTION CRITERIA

We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA.

DATA COLLECTION AND ANALYSIS

Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models.

MAIN RESULTS

We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time.

AUTHORS' CONCLUSIONS

There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.

Alveolar ventilation in children during flexible bronchoscopy

BACKGROUND

Hypoxia and hypercarbia complicate flexible bronchoscopy (FB). Unlike oxygenation by pulse-oximetry, alveolar ventilation is not routinely monitored during FB. The aim of this study was to investigate ventilation in children undergoing FB by measuring carbon-dioxide (CO₂ ) levels using the transcutaneous technique.

METHODS

Children admitted for FB were recruited. In addition to routine monitoring, transcutaneous CO₂ (TcCO₂ ) levels were recorded. All were sedated using the same protocol.

RESULTS

Ninety-five children were studied. There was no association between peak TcCO₂ or rise in TcCO₂ and age, weight percentile, bronchoscope size, or diagnosis. Median baseline TcCO₂ was 36 mmHg (IQR 32,40), median peak TcCO₂ was 51 mmHg (IQR 43,62) with median TcCO₂ rise of 17 mmHg (IQR 6.5,23.7). A rise of 15 mmHg or higher was recorded in 55% (n = 52) patients. Children requiring total propofol dose over 3.5 mg/kg had a significantly higher TcCO₂ peak of 57.6 mmHg (IQR 47.8,66.7) compared to 47.1 mmHg (IQR 40,57) (P = 0.004) and a higher rise in TcCO₂ 22.5 mmHg (IQR 17,33.9) compared to 13.6 mmHg (6,22) (P = 0.001). Results were not affected by intranasal midazolam and broncho-alveolar lavage. No complications were reported. Non clinically significant (i.e., not lower than 90%) brief drops in oxygen saturation were observed.

CONCLUSIONS

A large proportion of children undergoing FB have significant alveolar hypoventilation indicated by a rise in TcCO₂ . Monitoring ventilation with TcCO₂ is feasible and should be added during FB particularly in cases that are expected to require large amounts of sedation and patients susceptible to complications from respiratory acidosis. Pediatr Pulmonol. 2016;51:1177-1182. © 2016 Wiley Periodicals, Inc.

High-flow oxygen in patients undergoing procedural sedation in the emergency department: A retrospective chart review

OBJECTIVE

Hypoxia is a recognised complication of procedural sedation. This study sought to determine whether there was an association between the use of high-flow oxygen delivery by a non-rebreather (NRB) mask during ED procedural sedation and decreased rates of hypoxia when compared with alternative oxygenation methods.

METHODS

Records of all procedural sedations performed over a 12 month period in an Australian tertiary ED were reviewed retrospectively. The primary outcome was whether recorded oxygen saturations fell below 90%. Specifics of the oxygen delivery method were noted and data collected included sex, age, indication for sedation, drugs and doses administered, time of day sedation was commenced and staff grade of sedationist.

RESULTS

A total of 755 procedural sedations were reviewed. Two hundred and five (27.1%) patients were administered oxygen via NRB mask from the outset of their sedation. NRB administration was associated with a statistically significant decreased rate of hypoxia (1/205 patients vs 23/550 [odds ratio: 0.112; 95% confidence interval: 0.003-0.0702]; P = 0.0090). This association remained statistically significant when adjusted for confounders.

CONCLUSIONS

This study demonstrates an association with a statistically significant reduction in hypoxia when high-flow oxygen via NRB mask is administered during emergency procedural sedation. This intervention is simple, safe and inexpensive, and we would advocate that it be evaluated further in prospective trials.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Hypocapnia and hyperoxia induction using a hyperventilation protocol in electroconvulsive therapy

INTRODUCTION

Hyperventilation in electroconvulsive therapy sessions has been associated with seizure threshold, seizure characteristics, and cognitive effects. There is no consensus on the optimal procedure of applying hyperventilation manoeuvres during electroconvulsive therapy.

MATERIAL AND METHODS

Prospective evaluation of the effects of systematic use of hyperventilation manoeuvres with facial mask and capnography (protocolized hyperventilation [pHV]), on ventilation parameters and on seizures. The study included a sample of 130 sessions (65 performed according to hyperventilation standard practice and 65 successive sessions, with pHV) of 35 patients over a period of 10 weeks.

RESULTS

The pHV manoeuvres reduced exhaled CO₂ and increased O₂ saturation significantly (P<.001). The average CO₂ reduction achieved was 6.52±4.75mmHg (95% CI -7.7 to -5.3). The CO₂ values after pHV correlated significantly with seizure duration and O₂ values, with other electroencephalographic quality indices. In pHV sessions, compared with sessions performed according to hyperventilation standard practice, the average lengthening of the motor and electroencephalographic seizure was 3.86±14.62 and 4.73±13.95s, respectively. No differences were identified in other ictal quality parameters.

CONCLUSIONS

The proposed pHV manoeuvres significantly modify ventilation parameters. The hypocapnia and hyperoxia obtained by applying these manoeuvres lengthen the duration of seizures without worsening the quality of the electroencephalographic trace. The use of pHV is generalisable and might improve electroconvulsive therapy procedure without adding costs.

A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air

Objective:

Important questions remain regarding how best to monitor patients during procedural sedation and analgesia (PSA). Capnometry can detect hypoventilation and apnea, yet it is rarely used in emergency patients. Even the routine practice of performing preoxygenation in low-risk patients is controversial, as supplementary oxygen can delay the detection of respiratory depression by pulse oximetry. The purpose of this study was to determine whether the capnometer or the pulse oximeter would first detect respiratory events in adults breathing room air.

Methods:

During a randomized clinical trial comparing fentanyl with low-dose ketamine for PSA with titrated propofol, patients were monitored using pulse oximetry and continuous oral–nasal sampled capnography. Supplemental oxygen was administered only for oxygen desaturation. Sedating physicians identified prespecified respiratory events, including hypoventilation (end-tidal carbon dioxide &gt; 50 mm Hg, rise of 10 mm Hg from baseline or loss of waveform) and oxygen desaturation (pulse oximetry &lt; 92%). These events and their timing were corroborated by memory data retrieved from the monitors.

Results:

Of 63 patients enrolled, 57% (36) developed brief oxygen desaturation at some point during the sedation. All responded to oxygen, stimulation or interruption of propofol. Measurements of end-tidal carbon dioxide varied substantially between and within patients before study intervention. Hypoventilation (19 patients, 30%) was only weakly associated with oxygen desaturation (crude odds ratio 1.4 [95% confidence interval 0.47 to 4.3]), and preceded oxygen desaturation in none of the 12 patients in whom both events occurred (median lag 1:50 m:ss [interquartile range 0:01 to 3:24 m:ss]).

Conclusion:

During PSA in adults breathing room air, desaturation detectable by pulse oximeter usually occurs before overt changes in capnometry are identified.

A randomized controlled trial of capnography during sedation in a pediatric emergency setting

OBJECTIVE

Data suggest that capnography is a more sensitive measure of ventilation than standard modalities and detects respiratory depression before hypoxemia occurs. We sought to determine if adding capnography to standard monitoring during sedation of children increased the frequency of interventions for hypoventilation, and whether these interventions would decrease the frequency of oxygen desaturations.

METHODS

We enrolled 154 children receiving procedural sedation in a pediatric emergency department. All subjects received standard monitoring and capnography, but were randomized to whether staff could view the capnography monitor (intervention) or were blinded to it (controls). Primary outcome were the rate of interventions provided by staff for hypoventilation and the rate of oxygen desaturation less than 95%.

RESULTS

Seventy-seven children were randomized to each group. Forty-five percent had at least 1 episode of hypoventilation. The rate of hypoventilation per minute was significantly higher among controls (7.1% vs 1.0%, P = .008). There were significantly fewer interventions in the intervention group than in the control group (odds ratio, 0.25; 95% confidence interval [CI], 0.13-0.50). Interventions were more likely to occur contemporaneously with hypoventilation in the intervention group (2.26; 95% CI, 1.34-3.81). Interventions not in time with hypoventilation were associated with higher odds of oxygen desaturation less than 95% (odds ratio, 5.31; 95% CI, 2.76-10.22).

CONCLUSION

Hypoventilation is common during sedation of pediatric emergency department patients. This can be difficult to detect by current monitoring methods other than capnography. Providers with access to capnography provided fewer but more timely interventions for hypoventilation. This led to fewer episodes of hypoventilation and of oxygen desaturation.

Current applications of capnography in non-intubated patients

Current clinical guidelines recommend capnography as one of the best non-invasive methods to assess adequacy of ventilation in the non-intubated patient. Alveolar hypoventilation or respiratory depression is a serious event that occurs in a variety of clinical settings where patients receive sedatives and opioids. With the large number of procedures performed outside the operating room under the effects of sedatives and the increased use of patient-controlled analgesia, the need for capnography for monitoring has dramatically increased. Despite the succesful use of capnography to monitor ventilation in the operating room over several decades, other clinical areas have been very slow adapters of the technology and still rely heavily upon pulse oximetry to detect hypoventilation. This article reviews the most current evidence for using capnography in the non-intubated patient and summarizes the results of outcome measures reported in recent clinical trials. Capnography should be routinely used for non-intubated patients at risk for respiratory depression, in particular those receiving supplemental oxygen.

Percutaneous closure of atrial septal defects in spontaneously breathing children under deep sedation: a feasible and safe concept

Interventional cardiac catheterization in children and adolescents is traditionally performed with the patient under general anesthesia and endotracheal intubation. However, percutaneous closure of atrial septum defect (ASD) without general anaesthesia is currently being attempted in a growing number of children. The study objective was to evaluate the success and complication rate of percutaneous ASD closure in spontaneously breathing children under deep sedation. Retrospective single centre cohort study of consecutive children undergoing percutaneous ASD closure at a tertiary care pediatric cardiology centre. Transesophageal echocardiography (TEE) and percutaneous ASD closure were performed with the patient under deep sedation with intravenous bolus of midazolam and ketamine for induction and propofol continuous infusion for maintenance of sedation in spontaneously breathing children. One hundred and ninety-seven patients (median age 6.1 years [minimum 0.5; maximum 18.8]) underwent TEE and ASD balloon sizing. Percutaneous ASD closure was attempted in 174 patients (88 %), and device implantation was performed successfully in 92 %. To achieve sufficient deep sedation, patients received a median ketamine dose of 2.7 mg/kg (0.3; 7) followed by a median propofol continuous infusion rate of 5 mg/kg/h (1.1; 10.7). There were no major cardiorespiratory complications associated with deep sedation, and only two patients (1 %) required endotracheal intubation due to bronchial obstruction immediately after induction of sedation. Seventeen patients (8 %) had minor respiratory complications and required frequent oral suctioning or temporary bag-mask ventilation. TEE and percutaneous ASD closure can be performed safely and successfully under deep sedation in spontaneously breathing children of all ages.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction.

Etomidate for short pediatric procedures in the emergency department

OBJECTIVE

This study aimed to prospectively determine the etomidate dose associated with adequate sedation and few significant respiratory events for procedures of short duration in children.

METHODS

This is a prospective cohort study in an urban pediatric emergency department of patients 4 to 18 years requiring sedation and analgesia for painful procedures of short duration. Patients received fentanyl 1 μg/kg followed by intravenously administered etomidate 0.1 to 0.2 mg/kg as a loading dose. An additional dose of etomidate 0.1 mg/kg was intravenously administered if needed. The level of sedation was determined by The Children's Hospital of Wisconsin Sedation Score. The primary outcome was to determine the etomidate dose associated with an adequate level of sedation and procedural completion.

RESULTS

Sixty patients were enrolled. The most frequent procedure was fracture reduction (50/60, 83.3%). Procedures were successfully completed for 59 (98.3%) of 60 patients. The initial dose of etomidate associated with adequate sedation was 0.2 mg/kg intravenously administered for 33 (66.7%) of 50 patients requiring fracture reduction and for 6 (60.0%) of 10 patients receiving a procedure other than fracture reduction. Respiratory depression was noted in 9 (16.4%) of 55 patients, and oxygen desaturation was noted in 23 (39.0%) of 59 patients. Of 58 patients, 21 (36.2%) experienced a respiratory adverse event requiring brief intervention including oxygen supplementation, stimulation, and/or airway repositioning. No patient experienced a significant adverse respiratory event, defined as positive pressure ventilation. Median time to discharge-ready was 21 minutes.

CONCLUSIONS

For short-duration painful emergency department procedures, etomidate 0.2 mg/kg intravenously administered after fentanyl was associated with effective sedation, successful procedural completion, and readily managed respiratory adverse events in children.

[Measurement of carbon dioxide in emergency medicine]

Expiratory carbon dioxide (CO(2)) monitoring is a valuable tool in the prehospital setting. Recent reports of misplaced endotracheal tubes in the prehospital setting make it important to ensure that tube placement is verified by CO(2) monitoring. The Euronorm 2007:1789 made provision of capnometry mandatory for all medical vehicles. However, the frequency of utilization of CO(2) monitoring after securing the airway and in patients with respiratory insufficiency is low. This article covers the terminology, physiology, technology and clinical applications of CO(2) monitoring. Monitoring of cardiac output and the efficiency of cardiopulmonary resuscitation are described and the article also highlights the importance of CO(2) monitoring in patients with severe head trauma as well as restrictive and obstructive pulmonary disorders.

Procedural sedation with propofol for painful orthopaedic manipulation in the emergency department expedites patient management compared with a midazolam/ketamine regimen: a randomized prospective study

BACKGROUND

The use of procedural sedation and analgesia to allow painful orthopaedic manipulations in the emergency department has become a standard practice over the last decade. Both propofol and midazolam/ketamine are attractive sedative regimens for routine use in the emergency department. We hypothesized that sedation with propofol as compared with midazolam/ketamine will save time in the emergency department. The purpose of the present study was to compare the recovery time, the total sedation time, and the adverse events of procedural sedation and analgesia induced with propofol as compared with midazolam/ketamine.

METHODS

This prospective randomized study was conducted in the emergency department of a tertiary care, university-affiliated medical center. All sedations and orthopaedic manipulations were performed by trained and approved orthopaedic residents assisted by a registered nurse according to the same protocol. Sedation time and adverse events were recorded in real time.

RESULTS

Sixty adults (thirty-five men and twenty-five women) with a mean age (and standard deviation) of 45 ± 17 years were randomly enrolled in the study, with thirty patients being managed with each regimen. The average recovery time was 7.8 ± 3.7 minutes following sedation with propofol, compared with 30.7 ± 10.1 minutes following sedation with midazolam/ketamine (p < 0.001). The average total sedation time was 16.2 ± 3.8 minutes for the propofol group, compared with 41.6 ± 10.7 minutes for the midazolam/ketamine group (p < 0.001). The overall rate of respiratory and hemodynamic adverse events was 20% for the propofol group and 10% for the midazolam/ketamine group.

CONCLUSIONS

The use of propofol for an orthopaedic procedure requiring sedation in the emergency department expedites patient management and saves time in comparison with the use of midazolam/ketamine.

Utility of endtidal carbon dioxide monitoring in detection of hypoxia during sedation for brain magnetic resonance imaging in children with developmental disabilities

BACKGROUND

We have shown previously that children with developmental disabilities have three times higher incidence of sedation-related hypoxia when compared with normal children.

OBJECTIVES

Our objectives were to describe the changes in endtidal carbon dioxide (ETCO(2)) values and the utility of ETCO(2) monitoring in earlier identification of hypoxia during sedation for brain magnetic resonance imaging (MRI) in children with developmental disabilities.

METHODS

We conducted a prospective observational study of a convenience sample of 150 children with developmental disabilities aged 1-10 years who received intravenous sedation for brain MRI. Children were sedated and monitored according to the institution's sedation protocol. We recorded ETCO(2) levels, hypoxia, and adverse events during sedation. Hypoxia was defined as SpO(2) < 93%. A change in ETCO(2) level ≥ 10 mm Hg from presedation baseline, an intra-sedation ≥ 50 mm Hg, and loss of capnographic waveform were considered as significant ETCO(2) abnormalities.

RESULTS

Of the children, 80.7% (121/150) were sedated with a combination of pentobarbital and fentanyl. ETCO(2) abnormalities were noted in 42.6% (64/150) of sedation encounters. Hypoxia occurred in 18% (27/150) of subjects. ETCO(2) abnormalities were documented in 19(70%) patients with hypoxia before changes in pulse oximetry were noted. ETCO(2) changes were noted a mean of 4.38 ± 1.89 min prior to occurrence of hypoxia.

CONCLUSIONS

ETCO(2) abnormalities and hypoxia occur commonly during sedation in children with developmental disabilities. ETCO(2) monitoring is useful in early recognition of impending hypoxia during sedation in children with developmental disabilities.

Procedural sedation with propofol: a retrospective review of the experiences of an emergency medicine residency program 2005 to 2010

OBJECTIVES

The objective of this study is to evaluate the types and rates of adverse events associated with the use of propofol for procedural sedation by physicians from our emergency medicine residency program and compare those adverse event rates with those rates already published for all moderate and deep sedatives for procedural sedation, including propofol.

METHODS

This study was a retrospective chart review of all 215 procedural sedations performed with propofol in our emergency department (ED) from June 2005 to December 2010. The mean patient age was 29 years (SD, 22.1 years; range, 1-91 years). Adverse events were compiled and examined from chart data and compared with similar published studies on adverse event rates using propofol.

RESULTS

Of the 215 patients, 10 (4.65%) experienced adverse events related to procedural sedation with propofol. Our frequency of adverse events was not statistically different from the published rate for all moderate and deep sedatives (P = .407). Of all the adverse events, hypotension was the most common, occurring in 5 (2.33%) of the 215 patients. Of the 215 patients, 3 (1.40%) experienced brief hypoxia, with 2 (0.93%) of 3 patients requiring jaw thrust airway repositioning. Two (0.93%) of the 215 patients developed brief apnea that required brief bag valve mask-assisted ventilation. No patient required any advanced airway management. All 215 patients recovered completely from the procedural sedation and were discharged from the ED in stable and improved condition.

CONCLUSIONS

The adverse event rates from our study correlate with those of numerous earlier as well as recently published studies of moderate and deep sedatives, including propofol. The disciplined use of propofol by emergency physicians should continue to provide ED patients with the best available management options and care while additional focused and larger scale research is conducted to definitively confirm the premise that emergency physicians can continue to safely perform procedural sedation with propofol.

Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine

OBJECTIVES

Hypopneic hypoventilation, a decrease in tidal volume without a change in respiratory rate, is not easily detected by standard monitoring practices during sedation but can be detected by capnography. Our goal was to determine the frequency of hypopneic hypoventilation and its association with hypoxia in children undergoing sedation with ketamine.

METHODS

Children who received intravenous ketamine with or without midazolam for sedation in a pediatric emergency department were prospectively enrolled. Heart rate, respiratory rate, pulse oximetry, and end-tidal carbon dioxide (ET(CO2)) levels were recorded every 30 seconds.

RESULTS

Fifty-eight subjects were included in this study. Fifty percent of subjects had recorded ET(CO2) values less than 30 mm Hg without a rise in respiratory rate. Twenty-eight percent of subjects experienced a decrease in pulse oximetry less than 95%. Patients who experienced a persistent decrease in ET(CO2) at least 30 seconds in length were much more likely to have a persistent decrease in pulse oximetry than those with normal or transient decreases in ET(CO2) (relative risk, 6.6; 95% confidence interval, 1.4-30.5). Decreases in ET(CO2) occurred on an average of 3.7 minutes before decreases in pulse oximetry.

CONCLUSIONS

Hypopneic hypoventilation as detected by capnography is common in children undergoing sedation with ketamine with or without midazolam. Hypoxia is frequently preceded by low ET(CO2) levels. Further studies are needed to determine if the addition of routine monitoring with capnography can reduce the frequency of hypoxia in children undergoing sedation.

A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults

OBJECTIVES

The objective was to evaluate the effectiveness, recovery time, and adverse event profile of intravenous (IV) mixed 1:1 ketamine-propofol (ketofol) for adult procedural sedation and analgesia (PSA) in the emergency department (ED).

METHODS

  Prospective data were collected on all PSA events over a 4.5-year period in a trauma-receiving suburban teaching hospital. PSAs using a 1:1 single-syringe mixture of 10 mg/mL ketamine and 10 mg/mL propofol in patients over 21 years of age were analyzed. Physiologic data, drug doses, adverse events, recovery time, patient satisfaction, and staff satisfaction were recorded.

RESULTS

Ketofol PSA was used in 728 patients for primarily orthopedic procedures. Median patient age was 53 years (range = 21 to 99 years, interquartile range [IQR] = 36-70 years). The median dose of ketamine and propofol was 0.7 mg/kg each (range =0.2 to 2.7 mg/kg, IQR = 0.5-0.9 mg/kg), and median recovery time was 14 minutes (range = 3 to 50 minutes, IQR = 10-17 minutes). PSA was effective in 717 cases (98%). Bag-mask ventilation occurred in 15 patients (2.1%; 95% confidence interval [CI] = 1.0% to 3.1%). Recovery agitation occurred in 26 patients (3.6%; 95% CI = 2.2% to 4.9%), of whom 13 (1.8%; 95% CI = 0.8% to 2.7%) required treatment. One patient experienced vomiting and one patient was admitted to the hospital for monitoring of transient dysrhythmia and hypotension. No sequelae were identified. The median staff satisfaction scores were 10 (IQR = 9-10) on a scale of 1 to 10, and 97% of patients would have chosen the same method of PSA in the future.

CONCLUSIONS

  Ketofol is an effective PSA agent in adult ED patients. Recovery times are short and adverse events are few. Patients and ED staff were highly satisfied.

Pediatric sedation: a global challenge

Pediatric sedation is a challenge which spans all continents and has grown to encompass specialties outside of anesthesia, radiology and emergency medicine. All sedatives are not universally available and local and national regulations often limit the sedation practice to specific agents and those with specific credentials. Some specialties have established certification and credentials for sedation delivery whereas most have not. Some of the relevant sedation guidelines and recommendations of specialty organizations worldwide will be explored. The challenge facing sedation care providers moving forward in the 21st century will be to determine how to apply the local, regional and national guidelines to the individual sedation practices. A greater challenge, perhaps impossible, will be to determine whether the sedation community can come together worldwide to develop standards, guidelines and recommendations for safe sedation practice.

A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol)

OBJECTIVES

This study evaluated the effectiveness, recovery time, and adverse event profile of intravenous (IV) ketofol (mixed 1:1 ketamine-propofol) for emergency department (ED) procedural sedation and analgesia (PSA) in children.

METHODS

Prospective data were collected on all PSA events in a trauma-receiving, community teaching hospital over a 3.5-year period, from which data on all patients under 21 years of age were studied. Patients receiving a single-syringe 1:1 mixture of 10 mg/mL ketamine and 10 mg/mL propofol (ketofol) were analyzed. Patients received ketofol in titrated aliquots at the discretion of the treating physician. Effectiveness, recovery time, caregiver and patient satisfaction, drug doses, physiologic data, and adverse events were recorded.

RESULTS

Ketofol PSA was performed in 219 patients with a median age of 13 years (range = 1 to 20 years; interquartile range [IQR] = 8 to 16 years) for primarily orthopedic procedures. The median dose of medication administered was 0.8 mg/kg each of ketamine and propofol (range = 0.2 to 3.0 mg/kg; IQR = 0.7 to 1.0 mg/kg). Sedation was effective in all patients. Three patients (1.4%; 95% confidence interval [CI] = 0.0% to 3.0%) had airway events requiring intervention, of which one (0.4%; 95% CI = 0.0% to 1.2%) required positive pressure ventilation. Two patients (0.9%; 95% CI = 0.0% to 2.2%) had unpleasant emergence requiring treatment. All other adverse events were minor. Median recovery time was 14 minutes (range = 3 to 41 minutes; IQR = 11 to 18 minutes). Median staff satisfaction was 10 on a 1-to-10 scale.

CONCLUSIONS

Pediatric PSA using ketofol is highly effective. Recovery times were short; adverse events were few; and patients, caregivers, and staff were highly satisfied.

Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial

STUDY OBJECTIVE

We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol.

METHODS

Adults underwent ED propofol sedation with standard monitoring (pulse oximetry, cardiac and blood pressure) and capnography and were randomized into a group in which treating physicians had access to the capnography and a blinded group in which they did not. All patients received supplemental oxygen (3 L/minute) and opioids greater than 30 minutes before. Propofol was dosed at 1.0 mg/kg, followed by 0.5 mg/kg as needed. Capnographic and SpO2 data were recorded electronically every 5 seconds. Hypoxia was defined as SpO2 less than 93%; respiratory depression, as end tidal CO2 (ETCO2) greater than 50 mm Hg, ETCO2 change from baseline of 10%, or loss of the waveform.

RESULTS

One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%). Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds).

CONCLUSION

In adults receiving ED propofol sedation, the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.

Sedating the child with congenital heart disease

The number of pediatric patients requiring sedation for procedures performed outside the operating room environment continues to grow yearly, as does the number of patients surviving to adulthood with the residua and sequelae of congenital heart disease. Ongoing efforts to develop guidelines to enhance the safety of these pediatric sedative encounters have resulted in great strides in the prevention of adverse events. In addition, the Society for Pediatric Sedation, associated with the Pediatric Sedation Research Consortium, provides an important forum for practitioner education and the promotion of safe care for infants and children undergoing sedative experiences. Care of the subset of patients with congenital heart disease or pulmonary hypertension remains especially demanding. The additional safety challenges posed by remote locations make the highest level of vigilance essential when planning and performing sedation for these children.

Assessment of end-tidal carbon dioxide during pediatric and adult sedation for endoscopic procedures

BACKGROUND

Pulse oximetry has become the standard of care during endoscopic procedures, despite the fact that significant alveolar hypoventilation may be undetected.

OBJECTIVE

To study the value of end-tidal carbon dioxide (EtCO(2)) measurement during pediatric and adult endoscopic procedures with the patient under general anesthesia (GA) and conscious sedation (CS).

DESIGN AND SETTINGS

Oridion Microcap hand-held capnography by using Smart Bite Bloc with oxygen (O(2)) delivery were used for the procedures. Microstream nondispersive infrared (IR) spectroscopy is used to measure the concentration of molecules that absorb IR light in CO(2) exhaled by the subject. For each patient, we defined an "event" based on a combination of a >or=20% change (increase or decrease) in EtCO(2), with at least one of the following: O(2) saturation (SPO(2)) <or=90%, a >or=20% change of pulse rate or respiratory rate.

PATIENTS

We studied 57 patients, with an age range of 4 to 62 years. Nineteen patients (33.3%) had CS and 38 (66.6%) had GA.

RESULTS

Twenty patients had no events, 32 had 1 event, and 5 patients had 2 events. The highest observed frequency of an event was noted during upper endoscopy under GA (0.35), followed by upper endoscopy under CS (0.32). Fitted univariate logistic regression models indicated that higher variability in EtCO(2) is associated with a higher probability for an event (P < .0001) and that an increase in age is associated with a lower probability for an event (P < .0001). Significant differences in the frequencies of SPO(2) events were related to the type of procedure (P = .0002; highest estimated probability for upper endoscopy) and GA (P < .0001). Similar conclusions were obtained based on the fitted multivariate model.

CONCLUSIONS

EtCO(2) contributes significantly to the prediction of events during endoscopy. A lower mean of EtCO(2), higher variability of EtCO(2), younger age, GA, and upper endoscopy increase the probability of an event.