Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis

Navigating Pediatric Capnography: A Comprehensive Review of Scope and Limitations

This review comprehensively explores pediatric capnography, a vital tool in contemporary respiratory monitoring. The overview encompasses the foundational principles of capnography, elucidating its real-time measurement of carbon dioxide (CO2) in respiratory gases. The review emphasizes its paramount role in pediatric care and underscores capnography's significance in detecting respiratory abnormalities and guiding timely interventions. The distinctions between mainstream and sidestream capnography, the key to understanding their applications, are meticulously outlined. Addressing the importance of ongoing research and education, the review advocates for a dynamic approach to refine guidelines and optimize capnography utilization in pediatric settings. The conclusion reflects on the scope and limitations of pediatric capnography, acknowledging its transformative impact while advocating for a judicious recognition of constraints. As we navigate the future of pediatric respiratory care, the synergy of research, education, and clinical application emerges as the cornerstone for advancing pediatric capnography to new horizons.

Chronic kidney disease prevalence and clinical outcomes in anterior circulation acute ischemic stroke patients with reperfusion therapy: A meta-analysis

AIM

Chronic Kidney Disease (CKD) is a common comorbidity among acute ischaemic stroke (AIS) patients undergoing reperfusion therapies, including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). Acknowledging CKD's prevalence in this cohort and understanding its influence on outcomes is crucial for prognosis and optimizing care. This study aims to determine the prevalence of CKD among anterior circulation AIS (acAIS) patients undergoing reperfusion therapies and to analyse the role of CKD in mediating outcomes.

METHODS

A random-effects meta-analysis was conducted to pool and examine prevalence data. A total of 263 633 patients were included in the meta-analysis. The study assessed CKD's association with functional outcomes, symptomatic intracranial haemorrhage (sICH) and mortality.

RESULTS

The overall pooled prevalence of CKD among acAIS ranged from 30% to 56% in IVT-treated patients and 16%-42% for EVT-treated patients. CKD was associated with increased odds of unfavourable functional outcome at 90 days in both IVT (OR 1.837; 95% CI: [1.599; 2.110]; p < .001) and EVT (OR 1.804; 95% CI: [1.525; 2.133]; p < .001) groups. In IVT-treated patients, CKD was associated with increased odds of 30-day mortality (OR 6.211; 95% CI: [1.105; 34.909]; p = .038). CKD in IVT-treated patients exhibited increased odds of sICH, albeit statistically non-significant (OR 1.595; 95% CI: [0.567; 3.275]).

CONCLUSIONS

The high prevalence of CKD and its significant impact on outcomes in acAIS patients treated with reperfusion therapies underscore its clinical significance. This insight can guide personalised care strategies and potentially improve the prognosis in the management of acAIS.

New acoustic monitoring system quantifying aspiration risk during monitored anaesthesia care

Respiratory monitoring is crucial during monitored anaesthesia care (MAC) to ensure patient safety. Patients undergoing procedures like gastrointestinal endoscopy and dental interventions under MAC have a heightened risk of aspiration. Despite the risks, no current system or device can evaluate aspiration risk. This study presents a novel acoustic monitoring system designed to detect fluid retention in the upper airway during MAC. We conducted a prospective observational study with 60 participants undergoing dental treatment under MAC. We utilized a prototype acoustic monitoring system to assess fluid retention in the upper airway by analysing inspiratory sounds. Water was introduced intraorally in participants to simulate fluid retention; artificial intelligence (AI) analysed respiratory sounds pre and post-injection. We also compared respiratory sounds pre-treatment and during coughing events. Coughing was observed in 14 patients during MAC, and 31 instances of apnoea were detected by capnography. However, 27 of these cases had breath sounds. Notably, with intraoral water injection, the Stridor Quantitative Value (STQV) significantly increased; furthermore, the STQV was substantially higher immediately post-coughing in patients who coughed during MAC. In summary, the innovative acoustic monitoring system using AI provides accurate evaluations of fluid retention in the upper airway, offering potential to mitigate aspiration risks during MAC.Clinical trial number: jRCTs 062220054.

Capnography-An Essential Monitor, Everywhere: A Narrative Review

Capnography is now recognized as an indispensable patient safety monitor. Evidence suggests that its use improves outcomes in operating rooms, intensive care units, and emergency departments, as well as in sedation suites, in postanesthesia recovery units, and on general postsurgical wards. Capnography can accurately and rapidly detect respiratory, circulatory, and metabolic derangements. In addition to being useful for diagnosing and managing esophageal intubation, capnography provides crucial information when used for monitoring airway patency and hypoventilation in patients without instrumented airways. Despite its ubiquitous use in high-income-country operating rooms, deaths from esophageal intubations continue to occur in these contexts due to incorrect use or interpretation of capnography. National and international society guidelines on airway management mandate capnography's use during intubations across all hospital areas, and recommend it when ventilation may be impaired, such as during procedural sedation. Nevertheless, capnography's use across high-income-country intensive care units, emergency departments, and postanesthesia recovery units remains inconsistent. While capnography is universally used in high-income-country operating rooms, it remains largely unavailable to anesthesia providers in low- and middle-income countries. This lack of access to capnography likely contributes to more frequent and serious airway events and higher rates of perioperative mortality in low- and middle-income countries. New capnography equipment, which overcomes cost and context barriers, has recently been developed. Increasing access to capnography in low- and middle-income countries must occur to improve patient outcomes and expand universal health care. It is time to extend capnography's safety benefits to all patients, everywhere.

Patient Safety during Propofol Sedation before and after Implementation of Capnography Monitoring

Endoscopic procedures are routinely applied to cancer screening programs and surveillance. The preferred technique is usually deep sedation with propofol being a convenient agent allowing for a quicker patient recovery while maintaining a similar safety profile compared to traditional agents. However, adverse events, including respiratory depression and consequent undesirable cardiovascular side effects, may occur. The goal of this work is to evaluate the patient safety impact of adding capnography during endoscopic procedures under deep propofol sedation. Data were retrospectively collected from patients undergoing deep, procedural sedation for gastrointestinal (GI) endoscopy in October 2019 to January 2021 in a single Turkish university hospital. Included in the analysis were all adult patients classified by the American Society of Anesthesiologists (ASA) as I-IV, who were scheduled for GI endoscopy utilizing propofol alone or in combination. Data on 1840 patients were collected, of whom 1610 (730 pre- and 880 post-capnography implemention) met inclusion criteria. The primary outcome was a change in the composite incidence of mild oxygen desaturation (SpO2 75-90% for <60 s), severe oxygen desaturation (SpO2 < 75% anytime or <90% for >60 s), bradycardia (<60 ppm), and tachycardia (>25% from baseline). Without capnography, on average, 7.5 events of the primary endpoint were observed per 100 procedures and 2.9 with additional capnography monitoring (p < 0.001). A significant reduction was observed for mild oxygen desaturation, with a resulting odds ratio of 0.25 (95% CI 0.14 to 0.46). ASA I patients had the highest difference in combined incidence of any oxygen desaturation of 5.85% in the pre-capnography group and 0.64% in the post-capnography group. Although procedural sedation using propofol is not associated with severe adverse events, the incidence of composite adverse events could be reduced with the addition of capnography monitoring.

Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients

PURPOSE

To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence.

METHODS

Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology.

RESULTS

The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions.

CONCLUSIONS

Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.

Prognostic accuracy and impact of cerebral collateral status on clinical and safety outcomes in acute ischemic stroke patients receiving reperfusion therapy: a systematic meta-analysis

BACKGROUND

Cerebral collateral status has a potential role in mediating postreperfusion clinical and safety outcomes in acute ischemic stroke (AIS).

PURPOSE

To investigate the prognostic accuracy and impact of collateral status on clinical and safety outcomes in patients with AIS receiving reperfusion therapy.

MATERIAL AND METHODS

Studies with AIS patients treated with reperfusion therapy, collateral status assessed using Tan, ASITN/SIR, or similar collateral grading methods and data stratified according to collateral status were included. Relevant data on clinical outcomes, such as functional outcome at 90 days, mortality at 90 days, angiographic reperfusion, symptomatic intracerebral hemorrhage (sICH) and hemorrhagic transformation (HT), were collated and analyzed.

RESULTS

A meta-analysis of 18 studies involving 4132 patients with AIS was conducted. Good collateral status was significantly associated with angiographic reperfusion (odds ratio [OR]=1.97, 95% confidence interval [CI]=1.38-2.80; P < 0.0001), sICH (OR=0.67, 95% CI=0.46-0.99; P = 0.042), and 90-day functional outcome (OR=3.05, 95% CI=1.78-5.24; P < 0.0001). However, its association with HT (OR=0.76, 95% CI=0.38-1.51; P = 0.425) and three-month mortality (OR=0.53, 95% CI=0.17-1.69; P = 0.280) did not reach statistical significance. The prognostic accuracy of collaterals for predicting angiographic reperfusion, HT, functional outcome (at 90 days), and mortality (at 90 days) were 63%, 49%, 66%, and 48%, respectively.

CONCLUSION

Cerebral collaterals are significantly associated with clinical and safety outcomes, albeit with a prognostic accuracy range of 48%-66%; thus, evaluation of their patency is a useful prognostic tool in patients with AIS receiving reperfusion therapy.

Association of Lesion Topography with Functional Outcomes in Acute Ischemic Stroke Patients Considered for, or Receiving, Reperfusion Therapy: A Meta-Analysis

Background: The impact of lesion topography (LT), characterised by the Alberta Stroke Programme Early CT Score (ASPECTS), on outcomes after reperfusion therapy in acute ischemic stroke (AIS) is poorly elucidated. We investigated the prognostic accuracy of ASPECTS-based LT assessment and its association with clinical outcomes in AIS patients considered for reperfusion therapy or receiving intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), or none or both. Methods: Studies were identified from PubMed with additional studies added from Google Scholar. The prevalence of individual ASPECTS regions will also be determined. The association of individual ASPECTS regions with the functional outcome at 90 days will be assessed using random-effects modelling for various cut-offs, such as 6, 7 and 8. The association of continuous ASPECTS with the functional outcome at 90 days will also be undertaken. Forest plots of odds ratios (ORs) will be generated. Results: A total of 25 studies have been included in the final analysis, encompassing 11,404 patients. Pooled estimates indicate that the highest prevalence rates were in cases involving the insula and lentiform nucleus. Subgroup analysis for ASPECTS < 6 (OR 6.10; 95% CI 2.50−14.90; p < 0.0001), ASPECTS < 7 (OR 4.58; 95% CI 1.18−17.86; p < 0.0001) and ASPECTS < 8 (OR 2.26; 95% CI 1.32−3.89; p < 0.0001) revealed a significant association with poor functional outcome at 90 days. Decreasing ASPECTS significantly increased the odds of poor functional outcomes at 90 days (SMD −1.15; 95% CI −1.77−−0.52; p < 0.0001). Conclusions: Our meta-analysis demonstrates that decreasing ASPECTS is significantly associated with poor functional outcomes. Individual ASPECTS regions associated with the highest odds of poor functional outcomes were identified. Future studies on the association of LT and clinical outcomes specific to EVT are required.

Efficacy and safety in ketamine-guided prehospital analgesia for abdominal pain

Abdominal pain is a common reason for presentation in the emergency department and for calling emergency medical services. The complexity of abdominal pain also influences the analgesia strategy. However, there are almost no data on the use of ketamine for abdominal pain. This study aims to analyze the safety and efficacy of using ketamine as an analgesic for abdominal pain. In a retrospective analysis of prehospital patient data within the framework of quality assurance, all cases with ketamine administered by paramedics as analgesia for abdominal pain were analyzed in terms of pain reduction and patient safety and also compared with other analgesic drugs including fentanyl, morphine, and metamizole. From 01/01/2018 to 11/24/2021, 129 datasets were analyzed. The mean patient age was 50 ± 19 years (19-90 years), with 47.3% (n = 61) women. The application of fentanyl was documented as a monotherapy in 10.9% (n = 14), morphine in 2.3% (n = 3), metamizole in 34.1% (n = 44), and ketamine in 52.7% (n = 68) of cases. The pain relief of fentanyl, metamizole, and ketamine differed significantly from each other (p < 0.001), with fentanyl and ketamine being comparable. Looking at the quality assurance definition of successful analgesia (pain on handover NRS < 5 or pain reduction ≥ 2 points), successful analgesia was shown in 92.9% (n = 13) of cases for fentanyl, in 65.9% (n = 44) for metamizole, and 92.6% (n = 68) for ketamine (p < 0.001). Adverse events were not observed in patients treated with ketamine. Analgesia is an important goal in the treatment of patients with abdominal pain. With ketamine, analgesia comparable to fentanyl can be achieved. Ketamine appears to be a safe and effective option for the treatment of patients with abdominal pain in emergency medicine.Trial registration number DRKS00027343, date of registration: 09.12.2021, retrospectively registered.

Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review

BACKGROUND

Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal.

PURPOSE

To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke.

MATERIAL AND METHODS

We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies.

RESULTS

A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0-2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved.

CONCLUSION

CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.

Prognostic Role of the Platelet-Lymphocyte Ratio in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy: A Meta-Analysis

Background

Both inflammation and thrombotic/hemostatic mechanisms may play a role in acute ischemic stroke (AIS) pathogenesis, and a biomarker, such as the platelet-to-lymphocyte ratio (PLR), considering both mechanisms may be of clinical utility.

Objectives

This meta-analysis sought to examine the effect of PLR on functional outcomes, early neurological changes, bleeding complications, mortality, and adverse outcomes in AIS patients treated with reperfusion therapy (RT).

Design

Systematic Review and Meta-Analysis

Data Sources and Methods

Individual studies were retrieved from the PubMed/Medline, EMBASE and Cochrane databases. References thereof were also consulted. Data were extracted using a standardised data sheet, and systematic reviews and meta-analyses on the association of admission (pre-RT) or delayed (post-RT) PLR with defined clinical and safety outcomes were conducted. In the case of multiple delayed PLR timepoints, the timepoint closest to 24 hours was selected.

Results

Eighteen studies (n=4878) were identified for the systematic review, of which 14 (n=4413) were included in the meta-analyses. PLR collected at admission was significantly negatively associated with 90-day good functional outcomes (SMD=−.32; 95% CI = −.58 to −.05; P=.020; z=−2.328), as was PLR collected at delayed timepoints (SMD=−.43; 95% CI = −.54 to −.32; P<.0001; z=−7.454). PLR at delayed timepoints was also significantly negatively associated with ENI (SMD=−.18; 95% CI = −.29 to −.08; P=.001. Conversely, the study suggested that a higher PLR at delayed timepoints may be associated with radiological bleeding and mortality. The results varied based on the type of RT administered.

Conclusions

A higher PLR is associated with worse outcomes after stroke in terms of morbidity, mortality, and safety outcomes after stroke.

Service Evaluation of the Impact of Capnography on the Safety of Procedural Sedation

Background

Capnography has been associated with a reduced incidence of events related to respiratory compromise during procedural sedation.

Methods

A prospective service evaluation was conducted at a large United Kingdom (UK) teaching hospital to assess the impact of capnography on patient safety within four speciality services: bronchoscopy, endoscopy, interventional cardiology, and interventional radiology. Events were defined as provided by the World Society of Intravenous Anaesthesia. One thousand four hundred one patients were enrolled in the evaluation, with 666 patients before and 735 after implementation of capnography. Data was entered as a convenience sample on site in an offline data-collection tool. Results were assessed for the relative reduction in the incidence and resulting adjusted odds ratio for the combined incidence of oxygen desaturation (75–90% for <60s), severe oxygen desaturation (<75% at any time) or prolonged oxygen desaturation (<90% for >60s), bradycardia (>25% from baseline) and tachycardia (>25% from baseline). The adjusted odds ratio was controlled for both procedure and patient characteristics.

Results

After implementation of capnography, a significant reduction (43.2%, p ≤ 0.05) in adverse events was observed: 147 adverse events occurred during 666 procedures without capnography compared with 93 adverse events that occurred during 735 procedures with capnography. The adjusted odds ratio for the occurrence of the target adverse events was 0.57 (95% CI: 0.42–0.77). Multivariable linear regression indicated that capnography was a significant predictor (p 0.001) of reduced adverse events.

Conclusion

These results suggest improved patient safety following capnography implementation.

Role of Neutrophil-Lymphocyte Ratio in the Prognosis of Acute Ischaemic Stroke After Reperfusion Therapy: A Systematic Review and Meta-analysis

Background

Inflammation may mediate response to acute reperfusion therapy (RT) in acute cerebral ischaemia. Neutrophil-lymphocyte ratio (NLR), an inflammatory biomarker, may play an important role in acute ischaemic stroke (AIS) prognostication.

Objective

This meta-analysis sought to examine the effect of NLR on functional outcomes, mortality and adverse outcomes in AIS patients receiving RT.

Methods

Individual studies were retrieved from PubMed/Medline, EMBASE and Cochrane databases. Data were extracted using a standardised data sheet and meta-analysis on association of admission (pre-RT) or delayed (post-RT) NLR with clinical/safety outcomes after RT was conducted.

Results

Thirty-five studies (n = 10 308) were identified for the systematic review with 27 (n = 8537) included in the meta-analyses. Lower admission NLR was associated with good functional outcomes (GFOs), defined as 3-month modified Rankin scale (mRS) 0–2 (SMD = −.46; 95% CI = −.62 to −.29; P < .0001), mRS 0–1 (SMD = −.44; 95% CI = −.66 to −.22; P < .0001) and early neurological improvement (ENI) (SMD = −.55; 95 %CI = −.84 to −.25; P < .0001). Lower delayed admission NLR was also associated with GFOs (SMD = −.80; 95%CI = −.91 to −.68; P < .0001). Higher admission NLR was significantly associated with mortality (SMD = .49; 95%CI = .12 to .85; P = .009), intracerebral haemorrhage (ICH) (SMD = .34; 95% CI = .09 to .59; P = .007), symptomatic ICH (sICH) (SMD = .48; 95% CI = .07 to .90; P = .022) and stroke-associated infection or pneumonia (SMD = .85; 95% CI = .50, 1.19; P < .0001). Higher delayed NLR was significantly associated with sICH (SMD = 1.40; 95% CI = .60 to 2.19; P = .001), ICH (SMD = .94; 95% CI = .41 to 1.46; P < .0001) and mortality (SMD = 1.12; 95% CI = .57 to 1.67; P < .0001). There were variations in outcomes across RT groups.

Conclusion

Higher admission or delayed NLR is significantly associated with worse morbidity, mortality and safety outcomes in AIS patients receiving RT.

Delphi consensus on recommendations for the treatment of spinal muscular atrophy in Spain (RET-AME consensus)

INTRODUCTION

Spinal muscular atrophy (SMA) is a neurodegenerative disease caused by a biallelic mutation of the SMN1 gene, located on the long arm of chromosome 5, and predominantly affects the motor neurons of the anterior horn of the spinal cord, causing progressive muscle weakness and atrophy. The development of disease-modifying treatments is significantly changing the natural history of SMA, but uncertainty remains about which patients can benefit from these treatments and how that benefit should be measured.

METHODOLOGY

A group of experts specialised in neurology, neuropediatrics, and rehabilitation and representatives of the Spanish association of patients with SMA followed the Delphi method to reach a consensus on 5 issues related to the use of these new treatments: general aspects, treatment objectives, outcome assessment tools, requirements of the treating centres, and regulation of their use. Consensus was considered to be achieved when a response received at least 80% of votes.

RESULTS

Treatment protocols are useful for regulating the use of high-impact medications and should guide treatment, but should be updated regularly to take into account the most recent evidence available, and their implementation should be assessed on an individual basis. Age, baseline functional status, and, in the case of children, the type of SMA and the number of copies of SMN2 are characteristics that should be considered when establishing therapeutic objectives, assessment tools, and the use of such treatments. The cost-effectiveness of these treatments in paediatric patients is mainly influenced by early treatment onset; therefore, the implementation of neonatal screening is recommended.

CONCLUSIONS

The RET-AME consensus recommendations provide a frame of reference for the appropriate use of disease-modifying treatments in patients with SMA.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopy Facilities: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

There is increasing international recognition of the impact of variability in endoscopy facilities on procedural quality and outcomes. There is also growing precedent for assessing the quality of endoscopy facilities at regional and national levels by using standardized rating scales to identify opportunities for improvement.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of facilities where endoscopic care is provided to children. Consensus was reached via an iterative online Delphi process and subsequent in-person meeting. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 27 standards for facilities supporting pediatric endoscopy, as well 10 indicators that can be used to identify high-quality endoscopic care in children. These standards were subcategorized into three subdomains: Quality of Clinical Operations (15 standards, 5 indicators); Patient and Caregiver Experience (9 standards, 5 indicators); and Workforce (3 standards).

DISCUSSION

The rigorous PEnQuIN process successfully yielded standards and indicators that can be used to universally guide and measure high-quality facilities for procedures around the world where endoscopy is performed in children. It also underscores the current paucity of evidence for pediatric endoscopic care processes, and the need for research into this clinical area.

Quo Vadis Anesthesiologist? The Value Proposition of Future Anesthesiologists Lies in Preserving or Restoring Presurgical Health after Surgical Insult

This Special Issue of the Journal of Clinical Medicine is devoted to anesthesia and perioperative care [...].

Prevalence of paediatric hyperinflammatory conditions in paediatric and adolescent hospitalized COVID-19 patients: a systematic review and meta-analysis

In the milieu of coronavirus disease 2019 (COVID-19), there are increasing reports of paediatric hyperinflammatory conditions (PHICs), including multisystem inflammatory syndrome in children (MIS-C), paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS) and Kawasaki disease (KD). Few analyses of PHIC prevalence in paediatric and adolescent hospitalized COVID-19 patients exist. The purpose of this study was to perform a meta-analysis to determine a pooled prevalence estimate of PHICs in paediatric and adolescent hospitalized patients admitted for treatment due to COVID-19. Individual studies were retrieved from PubMed/Medline, EMBASE and Cochrane databases. Relevant prevalence, baseline, treatment and outcome data were extracted using a standardized datasheet. The systematic review and meta-analysis were conducted as per the PRISMA and MOOSE guidelines. Overall, 14 studies with 2202 patients admitted for treatment due to COVID-19, among whom 780 were diagnosed with PHICs, were included. The crude estimate of prevalence was 35.42%, and the pooled estimate of prevalence was 29% (random pooled ES = 0.29; 95% CIs = 0.18-0.42; p < 0.0001; z = 7.45). A sizeable proportion of paediatric and adolescent hospitalized patients admitted for treatment due to COVID-19 are diagnosed with a PHIC warranting a high index of clinical suspicion for PHICs. Further studies are required to validate these findings.

Implementing capnography to help improve patient safety during procedural sedation: quality improvement in a high-volume gastroenterology department

OBJECTIVE

Respiratory compromise is a major cause of adverse events during procedural sedation; continuous monitoring is vital for identifying and halting decompensation. We performed a quality improvement investigation to assess patient safety during procedural sedation in gastroenterology and the impact of implementing capnography monitoring.

PATIENTS AND METHODS

Sedation-related adverse events and interventions were prospectively recorded during the endoscopic procedure and in recovery. Assuming rates in published literature, power analysis determined that at least 1332 patients were required to show a 20% improvement in patient safety. Recorded sedation-related adverse events (mild and severe oxygen desaturations, bradycardia and tachycardia) and interventions were anonymized and aggregated to evaluate the quality improvement. Patient safety under current care was determined before capnography (Medtronic) was implemented in combination with training.

RESULTS

Between February 2018 and April 2018, a baseline (1092 patients) for outcomes under current care was completed, with 11.45 events per 100 procedures recorded. Between May 2018 and July 2018, 1044 procedures including capnography monitoring were performed with 5.08 events per 100 procedures recorded. The distribution of American Society of Anesthesiologists scores and procedure types between baseline and capnography were comparable. The absolute difference between baseline and capnography was -6.4 events per 100 procedures [95% confidence interval (CI), -4.1 to -8.7; P ≤ 0.0001]. The 55% reduction in adverse events surpassed the 20% improvement in patient safety set as the goal of this quality improvement. After multivariate regression, the adjusted odds ratio for events after implementation of capnography was 0.46 (95% CI, 0.32-0.66).

CONCLUSIONS

Addition of capnography to current care significantly decreased procedure-related safety events.

Stroke Aetiology and Collateral Status in Acute Ischemic Stroke Patients Receiving Reperfusion Therapy-A Meta-Analysis

BACKGROUND

The interplay between collateral status and stroke aetiology may be crucial in the evaluation and management of acute ischemic stroke (AIS). Our understanding of this relationship and its level of association remains sub-optimal. This study sought to examine the association of pre-intervention collateral status with stroke aetiology, specifically large artery atherosclerosis (LAA) and cardio-embolism (CE), in AIS patients receiving reperfusion therapy, by performing a meta-analysis.

METHODS

Relevant search terms were explored on Medline/PubMed, Embase and Cochrane databases. Studies were included using the following inclusion criteria: (a) patients aged 18 or above; (b) AIS patients; (c) patients receiving reperfusion therapy; (d) total cohort size of >20, and (e) qualitative or quantitative assessment of pre-intervention collateral status on imaging using a grading scale. Random-effects meta-analysis was performed to investigate the association of aetiology with pre-intervention collateral status, and forest plots of risk ratio (RR) were generated.

RESULTS

A meta-analysis was conducted on seven studies, with a cumulative cohort of 1235 patients, to assess the association of pre-intervention collateral status with stroke aetiology. Patients with LAA were associated significantly with an increased rate of good collaterals (RR 1.24; 95% CI 1.04-1.50; p = 0.020, z = 2.33). Contrarily, CE aetiology was associated significantly with a decreased rate of good collaterals (RR 0.83; 95% CI 0.71-0.98; p = 0.027, z = -2.213).

CONCLUSIONS

This study demonstrates that, in AIS patients receiving reperfusion therapy, LAA and CE aetiologies are associated significantly with collateral status.

High flow nasal oxygen, procedural sedation, and clinical governance

Procedural sedation for therapeutic and diagnostic procedures can now be achieved through deep sedation techniques that guarantee procedural success. Deep sedation techniques are delivered in a variety of non-theatre environments where the usual levels of anaesthetic equipment are not practical or economical. Hypoxic events are particularly frequent, and challenge sedation providers. Traditional low flow nasal or facial oxygen therapy techniques are often insufficient to maintain acceptable oxygen levels and prevent peri-procedural hypoxia. High flow nasal oxygen delivers warm humidified oxygen up to 70l/min, at oxygen concentrations between 21 - 100%, and reduces the incidence of hypoxic events. The provision of deep sedation is a complex process, fraught with risk, which can challenge even the skilled anaesthetist. Therefore, regulatory authorities previously stipulated that anaesthesia personnel be present during deep sedation. Changing attitudes by regulatory authorities and practical challenges providing anaesthesia specialists have led to the acknowledgement that appropriately trained non-anaesthetic staff can safely provide deep sedation. Deep sedation services are increasingly applied to subjects with complex comorbidities, sometimes excluded for safety reasons from surgery under general anaesthesia. The development of deep sedation services, delivered by non-anaesthesia personnel, to patients with complex co-morbidities requires that services implement appropriate clinical governance tools to prevent deep sedation being the wild west of anaesthesia services. Therefore, whilst high flow nasal oxygen may reduce the incidence of peri-procedural hypoxia, the introduction of clinical governance tools and the systematic introduction of initiatives to improve quality, will maintain the safety of deep sedation services.

Patient monitoring in the nonoperating room anesthesia (NORA) setting: current advances in technology

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) procedures continue to increase in type and complexity as procedural medicine makes technical advances. Patients presenting for NORA procedures are also older and sicker than ever. Commensurate with the requirements of procedural medicine, anesthetic monitoring must meet the American Society of Anesthesiologists standards for basic monitoring.

RECENT FINDINGS

There have been improvements in the required monitors that are used for intraoperative patient care. Some of these changes have been with new technologies and others have occurred with software refinements. In addition, specialized monitoring devises have also been introduced into NORA locations (depth of hypnosis, respiratory monitoring, point-of care ultrasound). These additions to the monitoring tools available to the anesthesiologist working in the NORA-environment push the boundaries of procedures which may be accomplished in this setting.

SUMMARY

NORA procedures constitute a growing percentage of total administered anesthetics. There is no difference in the monitoring standard between that of an anesthetic administered in an operating room and a NORA location. Anesthesiologists in the NORA setting must have the same compendium of monitors available as do their colleagues working in the operating suite.

Prehospital management of a non-intubated inhalation injury patient using transcutaneous monitoring of carbon dioxide

A 46-year-old man experienced facial burns due to a fire in his house. In the prehospital setting, suspecting inhalation injury and carbon monoxide poisoning, an emergency physician decided to bring him to the hospital for carbon dioxide (CO₂) monitoring without endotracheal intubation for approximately 20 min because of less severe respiratory distress. On the way to the hospital, the patient's end-tidal CO₂ monitoring ranged from 19 to 30 mm Hg, and transcutaneous carbon dioxide (TcPCO₂) remained between 50 and 55 mm Hg. On arrival at the hospital, PaCO₂ showed 51.6 mm Hg. Endotracheal intubation using a bronchoscope was performed in the emergency room, and inhalation injury was observed. He was extubated on day 5 and discharged on day 10. In the prehospital setting, TcPCO₂ monitoring is useful for initial management of non-intubated inhalation injury patients even with high concentration oxygen.

Ventilation Monitoring

Ventilation or breathing is vital for life yet is not well monitored in hospital or at home. Respiratory rate is a neglected vital sign and tidal volumes together with breath sounds are checked infrequently in many patients. Medications with the potential to depress ventilation are frequently administered, and may be accentuated by obesity causing airway obstruction in the form of sleep apnea. Sepsis may adversely affect ventilation by causing an increase in respiratory rate, often a very early sign of infection. Changes in ventilation may be early signs of deterioration in the patient.

National survey revealed variable practices in paediatric procedural sedation and patient monitoring

Paediatric procedures requiring sedation are increasingly being performed off site, but there are no national guidelines for paediatric procedural sedation in Finland or studies on it. Therefore, the aim of this survey was to assess national practices for paediatric procedural sedation outside operation rooms and intensive care units in terms of indications, sedative medication, treatment facilities, patient safety and training of the personnel. An online survey including single- and multiple-choice questions and open-ended questions was sent to Finnish paediatricians, paediatric surgeons and paediatric anaesthesiologists via the electronic mailing lists of national societies in December 2019. A total of 71 responses were received. Lumbar puncture (41%), intra-articular injections (38%) and MRI (17%) were the most common procedures that required routine sedation. Benzodiazepines were the most frequently used sedatives during both painful procedures (80%) and imaging (61%). Pulse oximetry monitoring was reported by 75% of the respondents, but other physiological parameters were rarely monitored (ECG 28%; blood pressure 39%; respiratory rate 34%). The level of sedation was not objectively assessed. Adrenaline (72%) and equipment for managing adverse respiratory outcomes (supplemental oxygen 98%; ventilation equipment 92%) were available in most facilities in which sedation was performed. Only one-third of the respondents had undergone training for paediatric procedural sedation, and only 39% of the hospital units compiled statistical data on sedation-related adverse events. The paediatric procedural sedation practices vary across hospitals. National guidelines for patient monitoring and training of personnel could improve treatment quality and patient safety.

Diagnostic and prognostic utility of computed tomography perfusion imaging in posterior circulation acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Computed tomography perfusion (CTP) imaging could be useful in the diagnosis of posterior circulation stroke (PCS) and in identifying patients who are likely to experience favorable outcomes following reperfusion therapy. The current study sought to investigate the diagnostic and prognostic capability of CTP in acute ischemic PCS by performing a systematic review and meta-analysis.

METHODS

Medline/PubMed and the Cochrane Library were searched using the terms: "posterior circulation", "CT perfusion", "acute stroke", and "reperfusion therapy". The following studies were included: (1) patients aged 18 years or above; (2) patients diagnosed with PCS; and (3) studies with good methodological design. Pooled sensitivity (SENS), specificity (SPEC), and area under the curve (AUC), computed using the summary receiver operating characteristic (SROC) curves, were used to determine diagnostic/prognostic capability.

RESULTS

Out of 14 studies included, a meta-analysis investigating diagnostic accuracy of CTP was performed on nine studies. Meta-analysis demonstrated comparable diagnostic accuracy of CTP to non-contrast computed tomography (NCCT) (AUC_CTP : 0.90 [95% CI 0.87-0.92] vs. AUC_NCCT : 0.96 [95% CI 0.94-0.97]); however, with higher pooled sensitivity (SENS_CTP : 72% [95% CI 57%-83%] vs. SENS_NCCT : 25% [95% CI 17%-35%]) and lower specificity (SPEC_CTP : 90% [95% CI 83%-94%] vs. SPEC_NCCT : 96% [95% CI 95%-98%]) than NCCT. Meta-analysis to determine prognostic capability of CTP could not be performed.

CONCLUSIONS

CTP has limited diagnostic utility in acute ischemic PCS, albeit with superior diagnostic sensitivity and inferior diagnostic specificity to NCCT. Further prospective trials are required to validate the prognostic capability of CTP-derived parameters in PCS.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

CTP-guided reperfusion therapy in acute ischemic stroke: a meta-analysis

BACKGROUND

Computed tomography perfusion (CTP) imaging could be useful in guiding reperfusion therapy or patient selection in acute ischemic stroke (AIS) patients. The aim of the current study was to determine the efficacy of the CTP-guided reperfusion therapy in AIS by performing a systematic review and meta-analysis.

METHODS

Medline/PubMed, Embase, and the Cochrane library were searched using the terms: "CT perfusion", "acute stroke" and "reperfusion therapy". The following studies were included: (a) studies reporting original data; (b) patients aged 18 years or above; (c) patients diagnosed with anterior circulation AIS; and (d) studies with good methodological design.

RESULTS

Twenty-two studies were finally included in the metanalysis with a total of 5, 687 patients. CTP-guided reperfusion therapy was associated with increased odds of good functional outcome without significant difference in safety profile.

CONCLUSIONS

CTP-guided reperfusion therapy improved functional outcomes in AIS, with increased benefits to patients treated with endovascular thrombectomy.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

[Analgesia for trauma patients in emergency medicine]

Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to <5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.

Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature

INTRODUCTION

Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated.

DISCUSSION

A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm.

CONCLUSIONS

ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.

Hypoxemia during procedural sedation in adult patients: a retrospective observational study

PURPOSE

Since 2010, new guidelines for procedural sedation and the Helsinki Declaration on Patient Safety have increased patient safety, comfort, and acceptance considerably. Nevertheless, the administration of sedatives and opioids during sedation procedures may put the patient at risk of hypoxemia. However, data on hypoxemia during procedural sedation are scarce. Here, we studied the incidence and severity of hypoxemia during procedural sedations in our hospital.

METHODS

A historical, single-centre cohort study was performed at the University Medical Centre Utrecht (UMCU), a tertiary centre in the Netherlands. Data from procedural sedation in our hospital between 1 January 2011 and 31 December 2018 (3,459 males and 2,534 females; total, 5,993) were extracted from our Anesthesia Information Management System. Hypoxemia was defined as peripheral oxygen saturation < 90% lasting at least two consecutive minutes. The severity of hypoxemia was calculated as area under the curve. The relationship between the severity of hypoxemia and body mass index (BMI), American Society of Anesthesiologists (ASA) Physical Status classification, and duration of the procedure was investigated. The primary outcome was the incidence of hypoxemia.

RESULTS

Twenty-nine percent of moderately to deeply sedated patients developed hypoxemia. A high incidence of hypoxemia was found in patients undergoing procedures in the heart catheterization room (54%) and in patients undergoing bronchoscopy procedures (56%). Hypoxemia primarily occurred in longer lasting procedures (> 120 min) and especially in the latter phases of the procedures. There was no relationship between severity of hypoxemia and BMI or ASA Physical Status.

CONCLUSIONS

This study showed that a considerable number of patients are at risk of hypoxemia during procedural sedation with a positive correlation shown with increasing duration of medical procedures. Additional prospective research is needed to investigate the clinical consequences of this cumulative hypoxemia.

Remifentanil for Procedural Sedation and Analgesia in Central Venous Catheter Insertion: A Randomized, Controlled Trial

OBJECTIVE

Central venous catheter (CVC) insertion is a common practice for anesthetists, but this invasive procedure generates anxiety and pain in patients that are often underestimated. We compared target-controlled infusion of remifentanil and local lidocaine infiltration with placebo and local lidocaine infiltration to decrease pain scores during CVC placement.

MATERIALS AND METHODS

We included conscious, adult patients without contraindication to remifentanil or lidocaine. We excluded pregnant women, emergency situations, and opioid abuse. Patients requiring CVC were randomly assigned, using computer-generated allocation numbers stored in sealed envelopes, to receive target-controlled infusion of remifentanil or placebo-all patients received local anesthesia with lidocaine. All patients were hospitalized in a recovery room or intensive care unit, monitored, and received 4 L/min of oxygen.The primary outcome was global pain (Verbal Numeric Rating Pain Scale) during the procedure. Secondary outcomes were pain perceived at every stage of the procedure, anxiety, patient satisfaction, operational ease, and side effects.

RESULTS

In this double-blind study, we included 90 patients (split into 2 groups of 45 patients). Global pain was significantly reduced in the remifentanil group: 20 of 100 (95% confidence interval, 16-40) versus 50 of 100 (95% confidence interval, 40-60) in the placebo group; P=0.0009. No major adverse events were observed during this study, and there were no significant differences between both groups regarding side effects.

DISCUSSION

Target-controlled infusion of remifentanil is an effective drug to reduce pain during CVC insertion in association with lidocaine-based local anesthesia, in conscious patients.

A mini-review of procedural sedation and analgesia in the emergency department

Procedural sedation and analgesia (PSA) is performed for a variety of indications in emergency departments (EDs). Although the practice of PSA in the ED is somewhat unique from other clinical areas, there is currently no guideline for this practice in Japan. Policy statements and guidelines for PSA have been published in Europe and North America. These guidelines suggest first evaluating patients carefully before performing PSA, and then deciding on target sedative level and choice of medications. Patient evaluation requires a combination of continuous visual observation by trained medical staff to assess the depth of sedation and respiration with noninvasive measurements of blood pressure, continuous electrocardiography monitoring, and pulse oximetry. Sedative selection should be based on its characteristics, peak time, effectiveness, and risks. It is important to administer sedatives and analgesics in small, incremental doses while keeping a close eye on the patient’s reaction to avoid adverse events (AEs) until the planned sedation level is reached. Further, additional attention is needed for special populations such as pediatric and elderly patients. PSA is a key element for patient‐centered care in emergency medicine. In this manuscript, we review the available evidence for PSA in the EDs, including guidelines for evaluation, monitoring, pharmacology, AEs, and special populations such as pediatric and elderly patients.

Prospective audit of sedation/anesthesia practices for children undergoing computerized tomography in a tertiary care institute

Background and Aims:

The aim of the study was to enumerate the sedative drugs used, assess the efficacy of sedative drugs, and determine the incidence of adverse events.

Material and Methods:

A prospective audit of children sedated for computerized tomography (CT) by anesthesiology team was conducted for a period of 4 months. The data included patient demographic variables, fasting period, medications administered, adequacy of sedation, imaging characteristics, adverse events, and requirement for escalated care.

Results:

A total of 331 children were enrolled for sedation by the anesthesia team. The drugs used for sedation were propofol, ketamine, and midazolam. Twenty-two percent children received one sedative drug, 60% children were administered two drugs, and 5% children required a combination of all three drugs for successful sedation. Sedation was effective for successful conduct of CT scan in 95.8% patients without the requirement of a repeat scan. Twelve (5%) children experienced adverse events during the study period. However, none of the adverse events necessitated prolonged postprocedural hospitalization or resulted in permanent neurologic injury or death.

Conclusions:

The current practice of sedation with propofol, ketamine, and midazolam, either single or in combination was efficacious in a high percentage of patients. The incidence of adverse events during the study period was low.

Nasal End-tidal Carbon Dioxide Monitoring during Procedural Sedation: Is it time for Wider Adoption?

How to cite this article: Ravikumar N, Nallasamy K. Nasal End-tidal Carbon Dioxide Monitoring during Procedural Sedation: Is it time for Wider Adoption? Indian J Crit Care Med 2020;24(8):611-612.

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.

Procedural sedation at role 1: applicability to military clinicians and minimum monitoring criteria

Procedural sedation is defined as producing a state of reduced consciousness, where the patient is still able to respond to verbal or physical stimulus and to continuously maintain a patent airway and adequate ventilation. This can be done to facilitate treatment that would not be otherwise possible. Recent evidence, guidelines and new equipment introductions have improved the safety of procedural sedation at UK role 1 medical treatment facilities (MTFs). A role 1 MTF is defined by the North Atlantic Treaty Organization as a medical facility focusing on the provision of primary healthcare, specialised first aid, triage, resuscitation and stabilisation, and is usually staffed by a general practitioner or a general duties medical officer. This paper aims to update role 1 clinicians on the current evidence base and guidance regarding monitoring of patients during procedural sedation.

Impact of Respiratory Compromise in Inpatient Interventional Radiology Procedures with Moderate Sedation in the United States

Background Despite increased use of moderate sedation in interventional radiology (IR), patient reactions to moderate sedation are difficult to predict. The rate, risk factors, and burden of respiratory compromise in patients who undergo IR procedures with moderate sedation in the United States are poorly understood. Purpose To identify risk factors and quantify the clinical and economic burden of respiratory compromise in inpatient IR procedures in the United States. Materials and Methods Primary inpatient IR procedures with moderate sedation conducted from October 1, 2012, to September 30, 2015, were analyzed by using a retrospective claims database. Exclusions included age younger than 18 years, use of anesthesia, pre-existing cardiac or respiratory arrest, and respiratory failure. Respiratory compromise was defined as use of naloxone or flumazenil, nonmechanical or cardiopulmonary resuscitation, or endotracheal intubation on the day of the IR procedure. Propensity score matching was performed to risk adjust patients for cost and outcomes analysis, including hospital and intensive care unit (ICU) length of stay, invasive mechanical ventilation, and death before hospital discharge. Results This study analyzed 525 151 patients (mean age, 60 years ± 17 [standard deviation]; 278 576 women). Respiratory compromise occurred in 1.0% (5235 of 525 151) of patients, predicted by long-term opioid therapy or active substance abuse (odds ratio [OR], 2.7; P < .001), age 65 years or older (OR, 1.4; P < .001), and sleep apnea (OR, 1.3; P < .001). Risk-adjusted patients with respiratory compromise compared with patients without respiratory compromise had $6904 higher costs (P < .001), 1.1-day longer hospital length of stay (P < .001), and higher rates of ICU admission (69.7% [3125 of 5235] vs 25.5% [1333 of 5235], respectively; P < .001), invasive mechanical ventilation (33.6% [1758 of 5235] vs 1.6% [85 of 5235], respectively; P < .001), and death (27.1% [1421 of 5235] vs 3.2% [166 of 5235], respectively; P < .001). Conclusion In the United States, respiratory compromise in interventional radiology procedures with moderate sedation contributes to worse clinical outcomes and higher costs. Respiratory compromise risk factors including long-term opioid therapy or active substance abuse, age 65 years or older, and sleep apnea should be preassessed and used to help guide intraprocedural monitoring to prevent respiratory compromise, improve patient outcomes, and reduce costs. © RSNA, 2019 See also the editorial by Rosen and Walz in this issue. Online supplemental material is available for this article.

Association of End-Tidal Carbon Dioxide Monitoring With Nurses' Confidence in Patient Readiness for Postanesthesia Discharge

PURPOSE

To determine if end-tidal carbon dioxide (etCO₂) value increased nurses' perceptions of confidence in patients' readiness for postanesthesia care unit (PACU) discharge.

DESIGN

Prospective, cross-sectional, comparative, one-group (pre-post) design.

METHODS

Nurses completed 2 assessments of confidence in readiness for discharge, before and after etCO₂ monitoring. Patient (discharge pain level, body mass index, sleep apnea history, and opioid use) and nurse factors were assessed. Analyses included descriptive and comparative statistics.

FINDINGS

Of 133 patients, mean (standard deviation) etCO₂ was 36.1 (5.7) mm Hg. Nurses' confidence in readiness for discharge differed before and after etCO₂ assessment. Confidence score decreased when etCO₂ was low (P = .003) or high (P = .005), compared with normal values. In linear regression, etCO₂ remained a factor in nurses' confidence in readiness for discharge (P < .001).

CONCLUSIONS

In a PACU, etCO₂ monitoring changed nurses' perceptions of confidence in patients' readiness for discharge.