Is capnography or end tidal CO2 assessment effective for monitoring adult patients in emergency departments or intensive care units who are undergoing moderate sedation or mechanical ventilation?

Bottom line:  There is evidence that associates capnography with improved detection of respiratory depression during procedural sedation and in management of mechanical ventilation.

Monitoring during moderate sedation:

PubMed search: (capnography OR end tidal carbon dioxide) AND sedation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Includes prospective studies, a systematic review and some lower quality comparative studies.

Higher quality study (Randomized controlled trial and prospective studies)
Proehl J, et al. J Emerg Nurs. 2011 Nov;37(6):533-6. Emergency Nursing Resource: the use of capnography during procedural sedation/analgesia in the emergency department.
Systematic review describes evidence from research studies, meta-analyses, systematic
reviews, and existing guidelines. Rates evidence using Appraisal of Guidelines Research & Evaluation methodology.

Deitch K, et al. Ann Emerg Med. 2010 Mar;55(3):258-64. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial.
Patients (n=132) in the ED who received propofol sedation received standard monitoring plus capnography and were randomized so that physicians administering care either had access to capnography readings or were blinded to capnography readings.  RESULTS:  Hypoxia was observed in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%).  Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds)

Burton JH, et al. Acad Emerg Med. 2006 May;13(5):500-4. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?
60 patients (enrollment stopped after review of 20 acute respiratory events) underwent capnographic monitoring while under procedural sedation. Abnormal end tidal CO2 findings were documented in 36 patients (60%). Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events.

Monitoring during mechanical ventilation

PubMed:  (capnography OR end tidal carbon dioxide) AND mechanical ventilation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Filters:  Systematic reviews

Walsh BK, Crotwell DN, Restrepo RD. Capnography/Capnometry during mechanical ventilation: 2011.  Respir Care. 2011 Apr;56(4):503-9.
Applied GRADE criteria to 200+ identified studies and guidelines. Includes several recommendations for use of capnography in monitoring patients on mechanical ventilation.

What are nurse retention rates at other emergency departments of teaching facilities and non-teaching facilities?

Bottom line: 4.46% of RN staff nurses left their EDs in 2007. It took an average of 57 days to fill vacancies. Data is from a survey of 700+ emergency departments in the US. Private, not-for-profit, teaching hospitals accounted for 36% of institutions represented and private, not-for-profit, non-teaching hospitals accounted for 22%.

Couselman FL, et al. A study of the workforce in emergency medicine: 2007. Am J Emerg Med. 2009; 27: 691-700
The study was funded by American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Emergency Medicine Foundation, Emergency Medicine Residents’ Association, ENA, GE Healthcare, and the Society for Academic Emergency Medicine.

Reviewed 4/21/2014 ldt

Communicating about evidence-based practice in patient care

Welcome. This blog facilitates communication on issues of evidence-based practice by Emory Healthcare Nursing Quality Initiatives teams. Questions posed by the teams and information to address those questions will be documented in these posts.