Identifying Early Opioid-Induced Respiratory Depression and Rapid Response Team Activation.

BACKGROUND: Opioids can cause respiratory depression, which could lead to patient harm. The project site noted a gap in identifying and monitoring postsurgical thoracic patients at risk for opioid-induced respiratory depression (OIRD), so an evidence-based solution was sought. AIMS: The purpose of this quality improvement project was to determine if translating the research by Khanna et al. (2020) on implementing the prediction of opioid-induced respiratory depression in patients monitored by capnography (PRODIGY) risk prediction tool would affect rapid response team (RRT) activation among postsurgical thoracic patients in a cardiovascular and thoracic care unit (CVTCU) at John Muir Medical Center, Concord Campus over four weeks. METHODS: The four-week quantitative quasi-experimental project had a total sample size of 29 participants. Pulse oximetry was used to identify OIRD in the comparison group (n = 12). The implementation group consisted of patients identified as at-risk for OIRD by the PRODIGY risk prediction tool and were monitored with pulse oximetry and capnography (n = 17). RESULTS: A χ2 analysis showed χ2 (1, n = 29) = .73, p = .393 for activation of the RRT using the PRODIGY risk prediction tool, which was not statistically significant. However, clinical significance was supported by a 5.9% increase in RRT activations. CONCLUSION: Based on the results, implementing the PRODIGY risk prediction tool and capnography monitoring on at-risk patients may affect RRT activation in this population.

Capnographic monitoring reduces hypoxia incidence in older patients undergoing gastrointestinal endoscopy under propofol sedation: study protocol for a multicenter randomized controlled trial.

BACKGROUND: Hypoxia is a very common adverse event that occurs during gastrointestinal endoscopy under sedation, especially in older patients, owing to limited reservation of heart, brain, lung, and other organs. Prolonged or severe hypoxia can cause ischemia of the coronary artery and permanent nervous system damage, and even result in death. Hence, it is imperative to reduce or prevent hypoxia during gastrointestinal endoscopy under sedation in older patients. Although several oxygen delivery methods would reduce hypoxia during this procedure, early detection of respiratory depression and early administration of intervention would be the best method to reduce or even confirm the hypoxia. Capnographic monitoring is reportedly more sensitive for detecting respiratory depression before the onset of hypoxia than the current clinical routine monitoring of pulse oxygen saturation; however, its effect is controversial. Therefore, in this study, we aimed to improve the safety of gastrointestinal endoscopy under sedation in older patients. METHODS: A multicenter, randomized, single-blind, two-arm parallel-group, controlled with an active comparator, interventional superiority clinical trial will be conducted to evaluate the impact of an additional capnographic monitoring-based intervention on the incidence of hypoxia in older patients. Patients (n = 1800) scheduled for gastrointestinal endoscopy with propofol sedation will be randomly assigned to either a control or interventional arm, wherein standard or capnographic monitoring is implemented, respectively. DISCUSSION: This study primarily aims to examine whether an additional capnographic monitoring-based intervention can reduce the incidence of hypoxia in older patients during gastrointestinal endoscopy under propofol and sufentanil sedation. The results of this study may extensively impact gastrointestinal endoscopy under sedation and the development of associated guidelines. TRIAL REGISTRATION: ClinicalTrials.gov NCT05030870. Registered on September 1, 2021.

Efficacy of capnographic and bispectral index monitoring on trans-oral therapeutic endoscopy: A prospective observational study.

BACKGROUND AND AIM: Oral therapeutic and invasive endoscopy requires deep sedation to reduce patient distress due to prolonged examination and procedures. The usefulness of capnography and bispectral index (BIS) monitoring in the early hypoxia detection in oral therapeutic and invasive endoscopy has yet to be evaluated. This study aimed to investigate the clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures. METHODS: This is a prospective observational study. Trans-oral non-intubated therapeutic and/or invasive endoscopic procedures were performed with conventional monitoring (pulse oximetry, pulse, and blood pressure) as well as additional monitoring (BIS and end-tidal CO2 concentration). Hypoxia is defined as oxygen saturation of <90% that lasts >15 s. The clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures were investigated with the risk factors for hypoxia in each patient. RESULTS: Patients with hypoxia had significantly more apneas detected using capnography than other patients. The multivariate analysis revealed the detected apnea by capnography as an independent risk factor for hypoxia (odds ratio: 3.48[95% confidence interval: 1.24-9.78], P = 0.02). The BIS was not significantly different as a risk factor for hypoxia; however, per-event analysis revealed significantly decreased BIS values over time in 3 min before hypoxic events. CONCLUSIONS: Apnea detected by capnography was an independent predictor of hypoxia. The BIS value was not associated with hypoxia events; however, it showed a significant downward trend before hypoxia events.

Capnography-sample line leak and incremental positive end expiratory pressure (PEEP); an interesting interplay.

The capnography is an important monitor to assess the patient's respiratory status. Importance of education for clinicians in interpretation of alarms and various capnography waveforms in different clinical scenarios and equipment malfunction is an understatement. Capnography waveforms due to sample line tube leak is described well in literature. This report describes an interesting effect of incremental positive end expiratory pressure (PEEP) on capnography waveforms linked to sample line leak.

Misinterpretation of carbon dioxide monitoring because of deadspace of heat and moisture exchanger with a filter in pediatric anesthesia: A case report.

RATIONALE: When patients are intubated and treated with mechanical ventilation, the upper respiratory tract is bypassed by the flow of dry and cold air. To prevent disturbances of airway homeostasis, a heat and moisture exchanger filter (HMEF) has been applied to breathing circuit. PATIENT CONCERNS: A 4-month-old male infant was ventilated with the pediatric HMEF. We report the impact of ignoring the direct influence of a filter containing deadspace in pediatric mechanical ventilation. DIAGNOSES: The breathing circuit with HMEF leads to unexpected complications such as mechanical obstructions owing to respiratory secretions, bleeding, inhaled drugs, and moisture. Besides these complications, we generally ignored the deadspace as the internal volume of the filters in breathing circuit for pediatric patients. INTERVENTIONS: After we noticed the influence of filter deadspace for pediatric patient, we removed the filter for effective respiratory circulation. OUTCOMES: The operation was completed without any specific incidents and the patient's voluntary breathing was well-maintained. The patient was discharged without any other complications. LESSONS: The increase in breathing apparatus deadspace should be minimized, and the clinicians should keep in mind that HMEF can causes respiratory acidosis with hypercapnia by apparatus deadspace rebreathing, especially for infants.

Monitoring ventilation with capnography.

Capnography, the graphic display of the exhaled and inhaled carbon dioxide concentration plotted against time, is used to monitor ventilation. This video reviews the principles of capnography and explains how to interpret the information it provides.