Patient Safety during Sedation and Analgesia Monitoring
Karen L. Green, MHA, BSN, RN, CRN Philadelphia, PA
[email protected] 4/16/2015
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4/16/2015
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Objectives
Discuss the trends of image-guided procedures/interventions.
State the regulatory agency’s positions surrounding Moderate Sedation.
Define the monitoring practices currently utilized.
List the benefits of initiating Capnography monitoring during Moderate Sedation. 4/16/2015
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How Did We Get Here?
Angiography Angioplasty – Stent GI Bleed – Arterial Embolization Biliary Drainage –Stents Nephrostomy Drainage - Stents Percutaneous Stone Extravasation Neurological Oncology Only time will tell … … 4/16/2015
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Today’s World
New image-guided technologies
Innovative therapies
Less Pain – Less Risk
Procedures to out-patient settings
Combination leads to ↑↑ patients 4/16/2015
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Today’s Patients
All age groups
Sicker
Frail health
Multi-system organ involvement
Previous surgeries and therapies
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Treatment Team Physician/Proceduralist
Nurse
Patient and Support System
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Technologist
FOCUS on specific areas
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Focus on IR Nurse
Investigate
Advocate
Educate
Communicate
Collaborate Courtesy of Emily Timmreck 4/16/2015
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Focus on Sedation
Continuum
Tolerate unpleasant procedures
Adequate cardio-pulmonary function
Respond purposefully
Rescue patient who slips deeper
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Moderate Sedation
Verbal Cooperative Intact airway reflexes Aspiration unlikely Airway obstruction unlikely Rapid recovery
Deep Sedation
Non-verbal Unable to cooperate Airway reflexes not intact Aspiration possible Airway obstruction likely Possible delayed recovery
Sedation Comparison 4/16/2015
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Focus on Safety
Pre-Procedure ◦ Introduce/Orient ◦ Fact finding (investigate) ◦ Educate
Procedure Suite ◦ ◦ ◦ ◦
Identify Position with dignity & comfort Safety Monitoring Small talk 4/16/2015
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Focus on Safety
Intra-Procedure ◦ ◦ ◦ ◦ ◦
Talk – touch –listen Monitor Medicate Communicate Advocate
◦ ◦ ◦ ◦
Evaluate Comfort Talk – touch – listen Educate
Post-Procedure
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Focus on Safety
Hand-off/report ◦ SBAR ◦ Safety ◦ Disposition – Transfer
Complete Documentation
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Patient Care Monitoring
NIBP EKG/ECG Pulse Oximetry Add Capnography
Baseline Assessment ◦ Is value WNL or abnormal
Trend Values
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Moderate Sedation Candidate
H&P Cardio-Pulmonary Assessment ASA Classification Mallampati Score Consent Solid IV access
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Supporting Information
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TJC The hospital monitors the patient during operative or high risk procedures and /or during the administration of moderate or deep sedation or anesthesia. EP: during operative or high risk procedures including … the administration of moderate or deep sedation or anesthesia, the patient’s oxygenation, ventilation, and circulation are monitored continually.
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ASA House of Delegates
Standard II: During all anesthesia, the patient’s oxygenation, ventilation, circulation, and temperature shall be continuously evaluated.
Standard III: To ensure adequate ventilation during all anesthetics. ◦ 3.2.4: … evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure or equipment. 4/16/2015
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Institute for Safe Medication Practices
“Do not rely on pulse oximetry readings alone to detect opiate toxicity.
Use Capnography to detect respiratory changes caused by opiates, especially for patients who are at high risk.
Establish guidelines for appropriate monitoring of patients who are receiving opiates, including frequent assessment of the quality of respirations (not just respiratory rate) and specific signs of over sedation. 2007 ISMP Medication Safety Alert
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ARIN Position Statement
Define/recognize the various levels of sedation.
Provide appropriate corresponding care.
Rescue patients
Capnography monitoring
No other concurrent responsibilities ARIN Position Statement: Role of the Imaging Registered Nurse in Patients Undergoing Sedated Procedures. August 2009.
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ARIN CPG ◦ ◦ ◦ ◦ ◦ ◦
Cardiac rate and rhythm NIBP Oxygen saturation Respiratory frequency Ventilatory status Depth of Sedation
ARIN CPG: Moderate Sedation and Analgesia. Rev. January, 2009
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SIR SOP: Capnography
Intent of the document is to make IR’s aware of the change to ASA Standard for moderate sedation”
“To encourage practitioner to consider the benefits of CO Capnography over Oximetry”
J Vasc Inter Radiol 2013; 24: 939-940.
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ACR-SIR Practice Parameter for Sedation/Analgesia Emergency Equipment Monitor
◦ ◦ ◦ ◦
Pulse Ox NIBP EKG – multi-lead Means of monitoring ventilation either visualization or through a device
◦ ACR-SIR Practice Parameter for Sedation /Analgesia, Amended 2014 (Resolution30)*
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Carlisle, H.
Respiratory Arrest
Capnography
◦ Contributing factor code situations ◦ Detects early signs of OIRD & promotes ◦ Respiratory depression
↓baseline respiratory depression RR 8-10 bp SaO₂ ↓90% EtCO₂ ↑50mm
Carlisle, H.: The case for capnography in patients receiving opioids.
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Jarzyna, et al
ASPMN: Evidenced Based Guidelines High risk group ◦ Renal dysfunction ◦ COPD ◦ Heart Failure ◦ Obesity ◦ OSA Loud snoring -> airway obstruction
Jarzyna et al. ASPMN Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression, 2011. 4/16/2015
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Focus on Capnography
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Capnography uses … Procedural Sedation ETT insertions / weaning N/G tube insertions Effectiveness of ventilator adjustments CPR
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Focus on Capnography
Continuous, real-time, non-invasive
Measures carbon dioxide
Mechanics of breathing
Initially intubated patient
From OR -> Procedure Suite
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Consider …
Characteristics: • Frequency • Rhythm • Height • Baseline • Shape 4/16/2015
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Normal Waveform A – B: Baseline period of no CO2, end of inhalation B – C: Rapid rise in CO2 C – D: Alveolar plateau D: End of expiration, end tidal CO2 D – E: Inhalation
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Hyperventilation Pattern SpO₂ - normal Assess patient for discomfort, anxiety
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Hypoventilation Pattern: Classic Assess ABCs Encourage deep breathing Reposition head/neck
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Shallow Breathing: Hypoventilation Significant change in Respiratory Rate Respiratory Depth decreases EtCO2 trends lower Inadequate gas exchange to eliminate CO2 4/16/2015
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Periods of “No Breath” Relaxation of soft palate and tongue obstructing the airway No chest wall or abdominal movement Obstructive apnea Capnography immediately alarms
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Rebreathing CO₂ Elevated base line Rebreathe CO2 in upper airway Insufficient O2 flow Reposition drape at face
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Sloping Expiratory Trace Upward slope Partial obstruction Bronchospasm COPD Asthma
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Focus on IR Specific Challenges
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IR Specific Issues
Full body drape
Partial neck and head drape
Prone position
Procedure room dimensions/layout
Overall population
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High Risk Patients
Bariatric Patient
COPD
CAD
Elderly
Pediatrics
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Focus on Nursing Actions
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Nurse – Specific Responses
Airway Management ◦ Deep Breathing ◦ Reposition head/neck ◦ Remove pillow
Assist Devices ◦ ◦ ◦ ◦ ◦ ◦
Non-rebreather mask Open airway: head tilt-chin lift Bi-Pap Bag Valve Mask Reversal medications RRT 4/16/2015
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Nursing Implications
No change in interventions
Facilitate interventions earlier ◦ Numerical change: > 10mm Hg ◦ Erratic waveform ◦ Flat waveform
Correlate med administration
May prevent over-sedation 4/16/2015
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Assess patient every 3-5 minutes and whenever changes are noted.
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Benefits of Capnography
Cost – benefit analysis
Enhance patient safety
Early detection/avoid complications
Decrease: legal liability reversal agent ABG
Exact $$$$$ difficult to predict 4/16/2015
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Focus on ARIN Survey Site of ARIN –NEC Fall Conference 2014
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Survey: Areas using Capnography
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Results: Not using Capnography
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Results: Organization Description Organization Description
50%
48%
24%
Academic (23/46) 50%
Community (22/46) 48%
Hospital (11/46) 24%
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4%
4%
Out-Patient (2/46) 4%
Rural (2/46) 4%
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Results: Facility Bed Size
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Re-cap
Include all aspects of assessment SpO₂ - late indicator of problems EtCO₂ - breath by breath picture Validates patient as candidate Allows earlier interventions Enhances patient safety
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Thank you.
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