End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study

doi:10.5847/wjem.j.1920-8642.2016.01.002

Abstract

Abstract:

BACKGROUND: This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED).
METHODS: The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction.
RESULTS: Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48% of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71%), cardioversion (12%) and abscess incision and drainage (12%) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO₂<90%) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9% vs. 9.3%, P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3%) patients in the ETC group and 7 (1.4%) in the control group (P=0.048).
CONCLUSIONS: The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

Key words: Procedural sedation and analgesia, Capnography, Adverse events, Emergency medicine

Samuel G. Campbell, Kirk D. Magee, Peter J. Zed, Patrick Froese, Glenn Etsell, Alan LaPierre, Donna Warren, Robert R. MacKinley, Michael B. Butler, George Kovacs, David A. Petrie. End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study[J]. World Journal of Emergency Medicine, 2016, 7(1): 13-18.

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References 20

1	Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxide monitoring during procedural sedation. Acad Emerg Med 2002; 9:275-280. doi: 10.1197/aemj.9.4.275
2	Wright SW. Conscious sedation in the emergency department: the value of capnography and pulse oximetry. Ann Emerg Med 1992; 21:551-555. pmid: 1570912
3	American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96:1004-1017. pmid: 11964611
4	Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO₂ monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010; 55:258-264. pmid: 19783324
5	Soto RG, Fu ES, Vila H Jr, Miguel RV. Capnography accurately detects apnea during monitored anesthesia care. Anesth Analg 2004; 99:379-382. pmid: 15271710
6	Green SM, Pershad J. Should capnographic monitoring be standard practice during emergency department procedural sedation and analgesia? Pro and con. Ann Emerg Med 2010; 55:265-267. pmid: 19819589
7	Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Acad Emerg Med 2006; 13:500-504. doi: 10.1197/j.aem.2005.12.017 pmid: 16569750
8	Waugh JB, Epps CA, Khodneva YA. Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis. J Clin Anesth 2011; 23:189-196.
9	Sivilotti ML, Messenger DW, van Vlymen J, Dungey PE, Murray HE. A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air. CJEM 2010; 12:397-404. doi: 10.1017/s1481803500012549 pmid: 20880431
10	Green SM, Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Ann Emerg Med 2003; 42:792-797. pmid: 14634604
11	Campbell SG, Petrie DA, MacKinley, Froese P, Etsell G, Warren DA, et al. PProcedural sedation and analgesia facilitator - expanded scope role for paramedics in the Emergency Department. Journal of Emergency Primary Health Care 2008; 6: [Article 990294]. Available from:http://www.jephc.com/full_article.cfm?content_id=486.
12	Guyenet PG, Stornetta RL, Bayliss DA. Central respiratory chemoreception. J Comp Neurol 2010; 518:3883-3906. doi: 10.1002/cne.22435 pmid: 20737591
13	Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation with propofol: a randomized, controlled trial. Ann Emerg Med 2008; 52:1-8.
14	Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial. Ann Emerg Med 2007; 49:1-8.
15	Deitch K, Chudnofsky CR, Dominici P, Latta D, Salamanca Y. The utility of high-flow oxygen during emergency department procedural sedation and analgesia with propofol: a randomized, controlled trial. Ann Emerg Med 2011; 58:360-364. pmid: 21680059
16	Green SM. Research advances in procedural sedation and analgesia. Ann Emerg Med 2007; 49:31-36. pmid: 17083997
17	Rogovik A, Goldman R. Permissive hypercapnia. Emerg Med Clin North Am 2008; 26:941-952. pmid: 19059093
18	Yldzdas D, Yapcoglu H, Ylmaz HL. The value of capnography during sedation or sedation/analgesia in pediatric minor procedures. Pediatr Emerg Care 2004; 20:162-165. pmid: 15094573
19	Langhan ML, Chen L, Marshall C, Santucci KA. Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine. Pediatr Emerg Care 2011; 27:394-397. doi: 10.1097/PEC.0b013e318217b538
20	Koniaris LG, Wilson S, Drugas G, Simmons W. Capnographic monitoring of ventilatory status during moderate (conscious) sedation. Surg Endosc 2003; 17:1261-1265. pmid: 12799890

Demographic data comparing the two samples		Control (n=501)	Capnometry (n=485)
Male, n (%)		281 (56)	236 (49)
ASA class	I	381	333
	II	102	129
	III	12	13
	Unknown	6	10
Procedure	Orthopedics	353	342
	Cardioversion	64	57
	Incision and drainage	56	65
	Chest tube placement	6	5
	Wound care	5	3
	Imaging/behaviour control	4	3
	Others	4	6
	Unknown	4	1
	Endoscopy	1	1
Comorbid status		83	124
Age (year)		45.6	47.4
Weight (lbs)		162.4	159.7
Height (in)		69.0	68.8

Variables	Propofol	Midazolam	Ketamine	Ketofol	P value
ETC	510 (94.6)	27 (5)	15 (2.8)	3 (0.6)	0.337
Standard care	424 (94.4)	12 (2.7)	12 (2.7)	3 (0.7)

Variables
Propofol use [mg/(kg?min)]	ETCO₂	Standard care
Range	0.010-2.870	0.014-1.196
Mean	0.173	0.180
Median	0.122	0.125
P value	0.572
95%CI	-0.032-0.180
Propofol use (mg)	AE	Non-AE
Range	30.0-560.0	20.0-480.0
Mean	141.7	142.3
Median	120.0	127.5
P value	0.944
95%CI	-19.8-18.5

Interventions	Control	Capnometry	P value
Airway repositioning	92 (18.4%, 95%CI 15.2-22.0)	127 (26.2%, 95%CI 22.5-30.3)	0.003
Positive pressure ventilation	2 (0.4%, 95%CI 0.1-1.4)	0 (0.0%, 95%CI 0.0-0.01)	0.164
Oral/nasal airway	1 (0.2%, 95%CI 0.04-1.2)	1 (0.2%, 95%CI 0.04-1.2)	0.982

Adverse events	Control	Capnometry	P value
Oxygen desaturation	7 (1.4%, 95%CI 0.7-2.9)	9 (1.9%, 95%CI 1.0-3.5)	0.569
Hypotension	7 (1.4%, 95%CI 0.7-2.9)	16 (3.3%, 95%CI 2.0-5.3)	0.048
Arrhythmia	0 (0.0%, 95%CI 0.0-0.01)	0 (0.0%, 95%CI 0.0-0.01)	N/A
Vomiting	0 (0.0%, 95%CI 0.0-0.01)	1 (0.2%, 95%CI 0.0-0.01)	0.309
None	465 (92.8%, 95%CI 90.2-94.8)	422 (87.0%, 95%CI 83.7-89.7)	0.002