High flow nasal oxygen during procedural sedation for cardiac implantable electronic device procedures: A randomised controlled trial

Place of high-flow nasal oxygen in nonoperating room anesthesia

PURPOSE OF REVIEW

This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings.

RECENT FINDINGS

The number of procedural interventions under deep sedation in NORA is still increasing. Administration of oxygen is recommended to prevent hypoxemia and is usually delivered with standard oxygen through nasal cannula or a face mask. HFNO is a simple alternative with a high warmed humidified flow (ranging from 30 to 70 l/min) with a precise fraction inspired of oxygen (ranging from 21 to 100%). Compared to standard oxygen, HFNO has demonstrated efficacy in reducing the incidence of hypoxemia and the need for airway maneuvers. Research on HFNO has primarily focused on its application in gastrointestinal endoscopy procedures. Yet, it has also shown promising results in various other procedural interventions including bronchoscopy, cardiology, and endovascular procedures. However, the adoption of HFNO prompted considerations regarding cost-effectiveness and environmental impact.

SUMMARY

HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.

Integrated pulmonary index during procedural sedation and analgesia: A cluster-randomized trial

AIM

To evaluate the effectiveness of utilizing the integrated pulmonary index for capnography implementation during sedation administered by nurses.

DESIGN

Cluster-randomized trial.

METHODS

Participants were enrolled from the interventional radiology department at an academic hospital in Canada. Nurses were randomized to either enable or disable the Integrated Pulmonary Index feature of the capnography monitor. Procedures were observed by a research assistant to collect information about alarm performance characteristics. The primary outcome was the number of seconds in an alert condition state without an intervention being applied.

RESULTS

The number of seconds in an alarm state without intervention was higher in the group that enabled the integrated pulmonary index compared to the group that disabled this feature, but this difference did not reach statistical significance. Likewise, the difference between groups for the total alarm duration, total number of alarms and the total number of appropriate alarms was not statistically significant. The number of inappropriate alarms was higher in the group that enabled the Integrated Pulmonary Index, but this estimate was highly imprecise. There was no difference in the odds of an adverse event (measured by the Tracking and Reporting Outcomes of Procedural Sedation tool) occurring between groups. Desaturation events were uncommon and brief in both groups but the area under the SpO2 90% desaturation curve scores were lower for the group that enabled the integrated pulmonary index.

CONCLUSION

Enabling the integrated pulmonary index during nurse-administered procedural sedation did not reduce nurses' response times to alarms. Therefore, integrating multiple physiological parameters related to respiratory assessment into a single index did not lower the threshold for intervention by nurses.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The time it takes to respond to capnography monitor alarms will not be reduced if the integrated pulmonary Iindex feature of capnography monitors is enabled during nurse-administered procedural sedation.

IMPACT

Results do not support the routine enabling of the integrated pulmonary index when nurses use capnography to monitor patients during procedural sedation as a strategy to reduce the time it takes to initiate responses to alarms.

REPORTING METHOD

CONSORT.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

TRIAL REGISTRATION

This study was prospectively registered at ClinicalTrials.gov (ID: NCT05068700).

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange Versus Conventional Facemask Breathing for Preoxygenation During Rapid Sequence Induction

INTRODUCTION

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), if used for pre-oxygenation and apnoeic oxygenation, has the propensity to extend the safe apnoea time and thereby decrease the incidence of desaturation during rapid sequence induction (RSI) for emergency surgeries. Hence, we proposed to evaluate the comparative efficacy of pre-oxygenation with the use of conventional facemask breathing versus THRIVE during RSI in patients undergoing general anaesthesia (GA) for emergency surgeries.

MATERIALS AND METHODS

Eighty patients undergoing RSI under GA for emergency abdominopelvic surgery were divided randomly into two groups. Patients were preoxygenated for three minutes with 100% oxygen via either a high-flow nasal cannula at a flow of 60 L/minute using THRIVE or a tightly-held, snuggly-fitting facemask at a flow of 12L/minute using a circle system. RSI was administered followed by laryngoscopy and endotracheal intubation. Arterial partial pressure of oxygen (PaO2) measured immediately after successful endotracheal intubation was our primary outcome. The lowest peripheral oxygen saturation (SpO2), apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and any adverse event were also recorded. Data thus collected were statistically analysed.

RESULTS

No statistically significant difference in PaO2 value was observed after successful intubation, lowest SpO2, apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and adverse event between both the groups (p>0.05).

CONCLUSION

We conclude that though not superior to conventional facemasks, THRIVE is a safe, practicable, and efficient pre-oxygenation tool during RSI of GA for patients undergoing emergency surgeries.

Clinical review of high-flow nasal oxygen therapy in human and veterinary patients

Oxygen therapy is the first-line treatment for hypoxemic acute respiratory failure. In veterinary medicine this has traditionally been provided via mask, low-flow nasal oxygen cannulas, oxygen cages and invasive positive pressure ventilation. Traditional non-invasive modalities are limited by the maximum flow rate and fraction of inspired oxygen (FiO₂) that can be delivered, variability in oxygen delivery and patient compliance. The invasive techniques are able to provide higher FiO₂ in a more predictable manner but are limited by sedation/anesthesia requirements, potential complications and cost. High-flow nasal oxygen therapy (HFNOT) represents an alternative to conventional oxygen therapy. This modality delivers heated and humidified medical gas at adjustable flow rates, up to 60 L/min, and FiO₂, up to 100%, via nasal cannulas. It has been proposed that HFNOT improves pulmonary mechanics and reduces respiratory fatigue via reduction of anatomical dead space, provision of low-level positive end-expiratory pressure (PEEP), provision of constant FiO₂ at rates corresponding to patient requirements and through improved patient tolerance. Investigations into the use of HFNOT in veterinary patients have increased in frequency since its clinical use was first reported in dogs with acute respiratory failure in 2016. Current indications in dogs include acute respiratory failure associated with pulmonary parenchymal disease, upper airway obstruction and carbon monoxide intoxication. The use of HFNOT has also been advocated in certain conditions in cats and foals. HFNOT is also being used with increasing frequency in the treatment of a widening range of conditions in humans. Although there remains conflict regarding its use and efficacy in some patient groups, overall these reports indicate that HFNOT decreases breathing frequency and work of breathing and reduces the need for escalation of respiratory support. In addition, they provide insight into potential future veterinary applications. Complications of HFNOT have been rarely reported in humans and animals. These are usually self-limiting and typically result in lower morbidity and mortality than those associated with invasive ventilation techniques.

Anaesthesia for minimally invasive cardiac procedures in the catheterization lab

PURPOSE OF REVIEW

The share of cardiac procedures performed in settings involving nonoperating room anaesthesia (NORA) continues to grow rapidly, and the number of publications related to anaesthetic techniques in cardiac catheterization laboratories is substantial. We aim to summarize the most recent evidence about outcomes related to type of anaesthetic in minimally invasive cardiac procedures.

RECENT FINDINGS

The latest studies, primarily focused on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr), demonstrate the need for reliable monitoring and appropriate training of the interdisciplinary teams involved in this high-risk NORA setting.

SUMMARY

Inappropriate sedation and concurrent inadequate oxygenation are main risk factors for claims involving NORA care. Current evidence deriving from TAVR shows that monitored anaesthesia care (MAC) is associated with shorter length of stay and lower mortality.