Do you monitor end tidal CO2? Here’s why you should
Do you monitor end tidal CO2? Here’s why you should
Currently, only a handful of EDs are monitoring ETCO2, but this number will increase dramatically in the near future, predicts Rebecca Meredith, RRT, respiratory therapy supervisor for the department of emergency services at the Cleveland Clinic Foundation.
This is not a requirement yet of the Joint Commission on Accreditation of Healthcare Organizations, "but may be in the future," she says. "It is moving toward becoming the standard of care."
At Cleveland Clinic, ED nurses work together with respiratory therapists to monitor ETCO2 for all patients undergoing procedural sedation. "Our ED’s protocol states that a respiratory therapist is present, and there is ETCO2 monitoring throughout the procedure," says Meredith.
Research shows that ETCO2 monitoring can detect adverse respiratory events such as hypoventilation, airway obstruction, and apnea before current standard ED procedural sedation monitoring practices, such as clinical observation and pulse oximetry.1
"I believe that many EDs will begin to utilize end tidal CO2 monitoring routinely for procedural sedation and analgesia patients," says John H. Burton, MD, the study’s lead author and director of research for the department of emergency medicine at Portland-based Maine Medical Center. "I believe that our study adds weight to the evidence currently available that suggests the potential value of this monitoring."
For ED nurses, the "learning curve is pretty small," says Burton. "End tidal CO2 monitoring utilizes detection of CO2 through nasal cannulae that are very similar to our current cannulae, allowing for CO2 detection and administration of O2," he says.
Most devices used in the ED plug into existing monitoring equipment with few modifications and allow for projection on the monitor screens alongside oxygen saturation, heart rate, cardiac rhythm, and blood pressure, adds Burton.
Maine Medical Center’s ED is implementing a policy requiring ETCO2 monitoring for all deep sedation encounters, including propofol, etomidate, and methohexital sedation. "Prior to this policy, we’ve been sporadic in our use," says Burton. "We also believe that the evidence revealed in our study is compelling toward the adoption of this policy."
Cleveland Clinic’s ED currently uses a capnometer, which gives a number indicating the ETCO2 level, but it is obtaining a capnographers which costs approximately $3,500, and also gives the ability to look at wave forms. "It gives you a visual look, and you can use the shape of the wave form as a diagnostic tool as well, to guide therapeutic intervention. We will hold inservices looking at wave forms and what the numbers tell the caregiver at the bedside," says Meredith.
Patients become hypercarbic and acidotic well before they become hypoxic which would be detected by pulse oximetry, she says. "By monitoring ETCO2, you catch it faster if patients are having a problem," Meredith says. "Their ETCO2 goes up — certainly before their pulse oximeter would go down — and we would intervene with bag mask ventilation to support their respiration. This avoids the side effects associated with hypoxia, such as respiratory arrest and cardiac arrhythmia."
ED nurses at Reedsburg (WI) Area Medical Center use a capnographer manufactured by Issaquah, WA-based Spacelabs Medical that cost $20,000 for the housing units and module. ETCO2 is monitored for all codes and respiratory distress patients, says Janet Volk, RN, director of the ED and intensive care unit. "We also do it on every patient that requires conscious sedation."
Capnography improves patient safety because it helps identify situations that lead to hypoxia, she says. "Uncorrected hypoxia can lead to permanent brain damage."
ETCO2 monitoring has long been standard of care for anesthesia and is now moving into EDs, she reports. "In the ED, we mainly use the side stream capnography," says Volk. It is an easy system to utilize and consists of a disposable side stream connector into the monitor, she says. "The CO2 wave form and number come up automatically on screen," Volk says.
If you need to perform a calibration, the system walks you through the process, she says. "Using capnography enables you to stay on top of respiratory problems your patient could encounter," Volk says. "Aside from monitoring CO2, it also has capability to monitor for periods of apnea, and respiratory rate."
At Cleveland Clinic, ETCO2 is used as a diagnostic tool for suspected pulmonary embolism (PE) patients. "If there is a normal VD/VT [alveolar dead space to tidal volume ratio] and a normal spirogram, you can rule out a PE with no need for more expensive diagnostic tests such as ventilation/perfusion scan, angiography, or MRI [magnetic resonance imaging]," says Meredith.2
References
- Burton JH, Harrah JD, Germann CA, et al. Does end-tidal carbon dioxide monitoring improve standard practice for predicting clinically important adverse respiratory events during emergency department procedural sedation and analgesia? Acad Emerg Med 2004; 11:489.
- Johanning JM, Veverka TJ, Bays RA, et al. Evaluation of suspected pulmonary embolism utilizing end-tidal CO2 and D-dimer. Am J Surg 1999; 178:98-102.
Sources/Resource
For more information on end tidal CO2 (ETCO2) monitoring in the ED, contact:
- John H. Burton, MD, Director of Research, Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St., Portland, ME 04102. Telephone: (207) 662-7048. E-mail: [email protected].
- Rebecca Meredith, RRT, Respiratory Therapy Supervisor, Department of Emergency Services, Cleveland Clinic Foundation, 9500 Euclid Ave., E19, Cleveland, OH 44195. Telephone: (216) 445-4554. E-mail: [email protected].
- Janet Volk, RN, ED/Intensive Care Unit Director, Reedsburg Area Medical Center, 2000 N. Dewey St., Reedsburg, WI 53959-1097. Telephone: (608) 524-6487, ext. 1080. E-mail: [email protected].
- The Ultraview SL Dual Capnography Module, manufactured by Spacelabs Medical, integrates mainstream and sidestream technology into a single module for monitoring ETCO2. Supplies are available in adult, pediatric, infant and neonatal sizes. For more information, contact: Spacelabs Medical, 5150 220th Ave. S.E., Issaquah, WA 98027-7018. Telephone: (800) 287-7108 or (425) 657-7200. Fax: (978) 552-7078. Web: www.spacelabs.com.
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