Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory: a modified Delphi study

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).

The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries

Aim

Traditional sedation management consists of doctors adjusting the dosage of sedative drugs or adding other drugs in combination according to the evaluation of nurses; the nurses then execute the orders. The nurses' passive execution in the process is not the ideal model for continuous evaluation and observation of sedation. This study aims to investigate the application and effects of nurse-provided procedural sedation and analgesia for patients in intensive care unit.

Methods

The experimental group consisted of 354 heart surgery patients who received procedural sedation and analgesia from nurses from November 2020 to August 2021. The control group consisted of 301 patients who had had heart surgery and received the traditional sedation management program from January to October 2020. The differences in levels of the sedative effect, delirium, and unplanned extubation of patients between these two groups were compared.

Results

There were no significant differences in baseline characteristics between the two groups (P > 0.05). It was found that both insufficient sedation and excessive sedation decreased in the experimental group when compared to the control group, while the appropriate proportion of sedation increased (72.41% versus 37.98%); the difference was statistically significant (P < 0.05). The incidence of delirium was lower for patients in the experimental group than for patients in the control group (37.01% versus 66.45%); the difference was statistically significant (P < 0.05). The incidence of unplanned extubation caused by patient factors was lower for the experimental group than for the control group, but the difference was not statistically significant (P > 0.05).

Conclusion

The programmed sedation scheme led by nurses can improve the sedation effect and reduce the incidence of delirium. Implications for Practice. The management team gives the sedative goal and establishes the standard flowchart. The sedation management led by the nurse according to the goal and flowchart is better than the traditional sedation management.

Predicting Prolonged Apnea During Nurse-Administered Procedural Sedation: Machine Learning Study

BACKGROUND

Capnography is commonly used for nurse-administered procedural sedation. Distinguishing between capnography waveform abnormalities that signal the need for clinical intervention for an event and those that do not indicate the need for intervention is essential for the successful implementation of this technology into practice. It is possible that capnography alarm management may be improved by using machine learning to create a "smart alarm" that can alert clinicians to apneic events that are predicted to be prolonged.

OBJECTIVE

To determine the accuracy of machine learning models for predicting at the 15-second time point if apnea will be prolonged (ie, apnea that persists for >30 seconds).

METHODS

A secondary analysis of an observational study was conducted. We selected several candidate models to evaluate, including a random forest model, generalized linear model (logistic regression), least absolute shrinkage and selection operator regression, ridge regression, and the XGBoost model. Out-of-sample accuracy of the models was calculated using 10-fold cross-validation. The net benefit decision analytic measure was used to assist with deciding whether using the models in practice would lead to better outcomes on average than using the current default capnography alarm management strategies. The default strategies are the aggressive approach, in which an alarm is triggered after brief periods of apnea (typically 15 seconds) and the conservative approach, in which an alarm is triggered for only prolonged periods of apnea (typically >30 seconds).

RESULTS

A total of 384 apneic events longer than 15 seconds were observed in 61 of the 102 patients (59.8%) who participated in the observational study. Nearly half of the apneic events (180/384, 46.9%) were prolonged. The random forest model performed the best in terms of discrimination (area under the receiver operating characteristic curve 0.66) and calibration. The net benefit associated with the random forest model exceeded that associated with the aggressive strategy but was lower than that associated with the conservative strategy.

CONCLUSIONS

Decision curve analysis indicated that using a random forest model would lead to a better outcome for capnography alarm management than using an aggressive strategy in which alarms are triggered after 15 seconds of apnea. The model would not be superior to the conservative strategy in which alarms are only triggered after 30 seconds.

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

BACKGROUND

High flow nasal oxygen may better support the vulnerable respiratory state of patients during procedural sedation.

OBJECTIVE

The objective of this study was to investigate the effects of high flow nasal oxygen in comparison to facemask oxygen on ventilation during cardiac implantable electronic device procedures performed with procedural sedation.

DESIGN

A randomised controlled trial.

SETTING

The study was conducted at one academic hospital in Canada.

PARTICIPANTS

Adults undergoing elective cardiac implantable electronic device procedures with sedation administered by an anaesthesia assistant, supervised by an anaesthesiologist from August 2019 to March 2020.

INTERVENTIONS

Participants were randomised 1 : 1 to facemask (≥ 8 l · min-1) or high flow nasal oxygen (50 l · min-1 and a 50 : 50 oxygen to air ratio).

MAIN OUTCOME MEASURES

The primary outcome was peak transcutaneous carbon dioxide. Outcomes were analysed using Bayesian statistics.

RESULTS

The 129 participants who were randomised and received sedation were included. The difference in peak transcutaneous carbon dioxide was 0.0 kPa (95% CI -0.17 to 0.18). Minor adverse sedation events were 6.4 times more likely to occur in the high flow nasal oxygen group. This estimate is imprecise (95% CI 1.34 to 42.99). The odds ratio for oxygen desaturation for the high flow nasal oxygen group compared with the facemask group was 1.2 (95% CI 0.37 to 3.75). The difference in satisfaction with sedation scores between groups was 0.0 (95% CI -0.33 to 0.23).

CONCLUSIONS

Ventilation, as measured by TcCO2, is highly unlikely to differ by a clinically important amount between high flow nasal oxygen at 50 l min-1 or facemask oxygen at 8 l min-1. Further research with a larger sample size would be required to determine the optimal oxygen:air ratio when using high flow nasal oxygen during cardiac implantable electronic device procedures performed with sedation.

TRIAL REGISTRATION NUMBER

NCT03858257.

Development and validation of the nursing confidence in managing sedation complications scale

Aim

To develop the Nursing Confidence in Managing Sedation Complications Scale.

Design

A multi‐phased approach was used.

Methods

An initial bank of items was created based on the authors' experience and clinical practice guidelines. An expert panel assessed content validity. Exploratory factor analysis was used for item reduction and regression was used to explore construct validity. Responsiveness was evaluated using a pre‐test post‐test design.

Results

Criteria for content validity was met for 34 items. An 18‐item, three‐factor solution was identified from exploratory factor analysis performed using Nursing Confidence in Managing Sedation Complications Scale scores from 228 nurses. Subscales accounted for 66% of the variance. Cronbach's alpha for the scale (0.95) and subscales was high (>0.85). There were differences (p < .001) in Nursing Confidence in Managing Sedation Complications Scale scores relative to years of experience and work environment. NC‐MSCS scores increased significantly from before to after sedation training (mean difference = 31.8; 95% CI = 24.4–39; N = 31).

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Intraprocedural Back Pain Associated with Awake Neuroendovascular Procedures

BACKGROUND AND PURPOSE

The prevalence and characteristics of intraprocedural back pain is not well studied in awake patients undergoing neuroendovascular procedures.

METHODS

We performed a prospective study as part of quality improvement initiative in which all patients who underwent neuroendovascular procedures in awake state were inquired regarding presence, severity (using a numeric rating scale score ranging from 0 [no pain] to 10 [worst pain possible]), and location (using anatomical chart) of back pain immediately after the procedure. The primary endpoint was the proportion of patients with moderate to severe pain (score of ≥3).

RESULTS

A total of 100 (41.3%) of 242 patients reported intraprocedural back pain with a median severity of 5/10 (range 1-10). The mean age was 58.7 ± 16.2 years. The mean duration of the procedure was 82.3 minutes (range 15-410 minutes). The pain was classified as moderate to severe in 86 of 100 patients. The locations of pain were identified in lumbar (n = 77), thoracic (n = 6), cervical (n = 7), cervical and lumbar (n = 8), and cervical with thoracolumbar (n = 2) regions. There was a significant relationship between patients' history of the previous neck and/or back surgery and frequency of moderate to severe back pain (P = .02). No significant relationship was observed between frequency of none to mild and moderate to severe back pain among the strata by patients' age, body mass index, or duration of procedures.

CONCLUSIONS

The relatively high prevalence of intraprocedural back pain in patients undergoing neuroendovascular procedures in awake state must be recognized, and strategies to reduce the occurrence need to be identified.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline

OBJECTIVE

Thoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients.

METHODS

Methods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey.

RESULTS

There was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated.

DISCUSSION

This project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.

Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care

OBJECTIVE

To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation.

DESIGN

Retrospective chart review.

METHODS

Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge.

SETTING

A single clinical site that employs seven expert nurses.

PARTICIPANTS

A total of 194 medical records were available for this analysis.

RESULTS

All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038).

CONCLUSION

Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.