Sedation of critical care patients undergoing mechanical ventilation is common, but all patients face the inherent risk of adverse events. In response, patient safety organizations advocate stricter monitoring.
The need to administer sedatives to patients receiving mechanical ventilation is common: in fact, according to a study in the American Journal of Critical Care, 85% of ICU patients receive intravenous sedatives in order to reduce the anxiety, pain, and agitation associated with mechanical ventilation.1
However, the use of sedation carries real risks. Inappropriately high levels of sedation, which are associated with the use of continuous intravenous infusions of sedatives, may “lead to alterations in respiratory drive, inability to maintain and protect the airway, and unstable cardiovascular status, as well as prolonged duration of mechanical ventilation and ventilator-associated pneumonia.”1 By contrast, insufficient levels of sedation may result in “agitation, placing intubated patients at risk for self-extubation, unstable hemodynamic status, and physical harm or injury.”1
As a result, healthcare safety organizations, such as The Joint Commission, continue to call for more monitoring safeguards for patients, and awareness for clinicians.2 Similarly, the patient safety organization Physician-Patient Alliance for Health & Safety (PPAHS), recently issued an alert to clinicians about the safety of pediatric patients being sedated for common critical care procedures, such as fracture reduction, laceration repair, and incision and drainage of an abscess. The organization has consistently called for continuous patient monitoring for patients being administered opioid analgesics, specifically with capnography.
In a PPAHS video presentation by Dr Melissa Langhan, assistant professor of Pediatrics, Emergency Medicine, at Yale School of Medicine, several case studies demonstrate the advantage of capnography use for pediatric patients. According to a study that she published in Pediatric Emergency Care, 72% of the episodes of prolonged hypoxia were preceded by decreases in EtCO2 as measured by capnography. The use of capnography would enhance patient safety by decreasing the frequency of hypoxia during sedation in children, according to PPAHS.
In the video, Langhan discusses case studies, such as one involving an intoxicated adolescent being continuously electronically monitored with capnography, as well as with pulse oximetry and a heart rate monitor. “As I walked by the room, I heard his capnography monitor beeping, and when I went in there, the patient was apneic. Meanwhile his heart rate monitor and his pulse oximetry were all normal,” Langhan explained in a press release. “No one may have noticed that he had become apneic if it hadn’t been for that monitor.”
“Unfortunately, continuous capnography is not routinely used outside of the operating room. Capnography can really enhance patient safety, and healthcare professionals need to think about using it more often. As our study found, using capnography enhanced patient safety, by being able to detect declines in end tidal CO2 indicating hypoventilation which could lead to hypoxemia.”
In order to increase awareness of the benefits of capnography for critical care patients, PPAHS has created an educational series on continuous patient monitoring. Beginning October 2015, the 10-part clinical education series will feature key topics, including: the return on investment (ROI) of continuous monitoring, reduction of rescue events, changes in workflow, alarm management, effective nursing bedside strategies and tips, and risk stratification and patient assessment. The ultimate goal of the series, which is sponsored by Medtronic and EarlySense, is to improve healthcare by preventing adverse events and death, according to PPAHS.
“This clinical education series will feature doctors, nurses and respiratory therapists discussing how they have successfully implemented continuous patient monitoring in their hospitals,” Michael Wong, JD, executive director, PPAHS, said via a press release. “The series will also address how these hospitals and clinicians were able to overcome challenges to implementing monitoring.” RT
Grap, MJ, et al. “Sedation in adults receiving mechanical ventilation: Physiological and comfort outcomes.” Am J Crit Care. May 2012. 21:3. http://dx.doi.org/10.4037/ajcc2012301
The Joint Commission Sentinel Event Alert: Safe use of opioids in hospitals. Issue 49, August 8, 2012 The Joint Commission. http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf