Original ContributionA randomized controlled trial of capnography during sedation in a pediatric emergency setting☆,☆☆,★
Introduction
Capnography, or continuous end-tidal carbon dioxide (ETCO2) monitoring, is a sensitive indicator of ventilation that can alert a provider to hypoventilation more often and earlier than other modalities [1], [2], [3]. In nonintubated patients, it is measured passively via a nasal-oral cannula in a continuous and objective manner [4], [5]. Capnography can detect hypoventilation and apnea before it becomes apparent by clinical examination or pulse oximetry, yet is infrequently used in monitoring children during sedation in an outpatient or pediatric emergency department (PED) setting despite promotion by agencies such as the Joint Commission [2], [6], [7], [8], [9], [10], [11], [12], [13]. The detection of apnea or hypoventilation can be significantly delayed by use of pulse oximetry alone, particularly if patients receive supplemental oxygen [1], [14], [15], [16], [17], [18].
Children in the PED frequently need medications for procedural sedation, which induces a state of attenuated pain, anxiety and motion to facilitate procedures such as fracture reduction or drainage of abscesses [19], [20], [21]. Although sedation is generally safe, it may lead to hypoventilation due to alterations in a patient's respiratory rate or tidal volume. Although the normal respiratory rate varies by age, providers may follow trends with impedance plethysmography or clinical examination. However, tidal volume is less easy to quantify. Hypopnea, a decline in tidal volume, is not detectable by monitoring either respiratory rate or other standard parameters and is difficult to detect on physical examination. However, hypopnea commonly occurs during sedation and often precedes hypoxemia [2], [7], [22], [23].
This is the first randomized trial to examine the effects of capnography on detecting hypoventilation and preventing hypoxemia during sedation among children in the PED. We hypothesized that the addition of capnography to standard monitoring would significantly improve recognition of hypoventilation by providers caring for sedated children. This improved recognition might increase the rate of interventions to prevent continued hypoventilation and reduce the rate of oxygen desaturations, thus improving patient safety.
Section snippets
Study design and setting
This was a randomized, controlled trial of capnography in a PED within an urban, tertiary care academic center from September 1, 2011, to January 31, 2013. The PED is staffed by 13 pediatric emergency medicine attendings, 6 fellows, and approximately 50 registered nurses.
Population
Children aged 1 to 20 years given intravenous medications to induce sedation were eligible for inclusion. Exclusion criteria included intubation, administration of baseline supplemental oxygen without preceding hypoxemia, and
Results
There were 194 children approached for enrollment. Twenty-seven potential subjects were excluded: 18 refused to participate, 4 were not sedated or study personnel were unavailable, 3 did not tolerate the cannula, and cannula interfered with the procedure in 2 (eg, nasal laceration). Thirteen patients were excluded after randomization (7 controls, 6 cases): 11 for crying during greater than 20% of the sedation, 1 was younger than 1 year, and 1 used a pacifier which obstructed the cannula.
Discussion
This is the first randomized trial in children to assess the impact of the addition of capnography to standard monitoring during sedation in a PED. We found that capnography benefited patients by reducing the rate of hypoventilation in subjects over time, improving the timeliness of interventions, and impacting the frequency of oxygen desaturations when timely interventions were performed.
It is important to note that all episodes of hypoventilation in this study were caused by hypopnea. The low
Limitations
There are several potential limitations to our study. Our primary outcome was a pulse oximetry reading less than 95%, with a reading less than 90% as a secondary measure. Although the direct patient morbidity associated with oxygen desaturations is unknown, the administration of supplemental oxygen without the ability to continuously monitor a patient's ventilatory status can mask continued respiratory depression and can lead to respiratory arrest. Similarly, a consensus panel on pediatric
Conclusions
In summary, hypopneic hypoventilation is common among children receiving sedation in a PED and is difficult to detect other than by capnography. Providers with access to capnography during sedation provided fewer, but more timely interventions for hypoventilation. This was associated with fewer episodes of hypoventilation and fewer episodes of oxygen desaturation. Although larger studies are needed to assess the impact of capnography on more serious adverse events, capnography may improve the
References (52)
- et al.
Utility of monitoring capnography, pulse oximetry, and vital signs in the detection of airway mishaps: a hyperoxemic animal model
Am J Emerg Med
(1998) - et al.
Capnography for procedural sedation and analgesia in the emergency department
Ann Emerg Med
(2007) - et al.
Capnography and depth of sedation during propofol sedation in children
Ann Emerg Med
(2007) - et al.
The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial
Ann Emerg Med
(2007) Conscious sedation in the emergency department: the value of capnography and pulse oximetry
Ann Emerg Med
(1992)- et al.
Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update
Ann Emerg Med
(2011) - et al.
Supplemental oxygen impairs detection of hypoventilation by pulse oximetry
Chest
(2004) - et al.
A model to describe the rate of oxyhaemoglobin desaturation during apnoea
Br J Anaesth
(1996) - et al.
Procedural sedation and analgesia in children
Lancet
(2006) Sample size and power calculations with correlated binary data
Control Clin Trials
(2001)
Clinical policy: procedural sedation and analgesia in the emergency department
Ann Emerg Med
Continuous end-tidal carbon dioxide monitoring in pediatric intensive care units
J Crit Care
Evaluation of cerebral oxygenation during procedural sedation in children using near infrared spectroscopy
Ann Emerg Med
Nurse reports of adverse events during sedation procedures at a pediatric hospital
J Perianesth Nurs
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
Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography
Gastroenterology
Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?
Acad Emerg Med
Noninvasive capnometry in a pediatric population with respiratory emergencies
Pediatr Emerg Care
Noninvasive monitoring of end-tidal CO2 via nasal cannulas in spontaneously breathing children during the perioperative period
Crit Care Med
The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department
Pediatr Emerg Care
The value of capnography during sedation or sedation/analgesia in pediatric minor procedures
Pediatr Emerg Care
Current utilization of continuous end-tidal carbon dioxide monitoring in pediatric emergency departments
Pediatr Emerg Care
Sedation provider practice variation: a survey analysis of pediatric emergency subspecialists and fellows
Pediatr Emerg Care
Age and the onset of desaturation in apnoeic children
Can J Anaesth
Duration of apnoea in anaesthetized children required for desaturation of haemoglobin to 95%: comparison of three different breathing gases
Paediatr Anaesth
Delayed detection of hypoxic events by pulse oximeters: computer simulations
Anaesthesia
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2021, American Journal of Emergency MedicineCitation Excerpt :End-tidal capnography has already been used in adult ED settings, where etCO2 > 50 mmHg has been found to be a good predictor for intubation, critical care time, and increased mortality in those with obstructive airway diseases such as asthma [32]. Additionally, etCO2 capnography monitoring is widely used in pediatric ED procedural sedation, and has been shown to be a more sensitive, instantaneous indicator of ventilation status than pulse oximetry [33]. Unfortunately, only two studies have examined infants with bronchiolitis and their etCO2 capnography values [34,35].
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2021, ResuscitationCitation Excerpt :Several studies show reasonable correlation between ETCO2 and PaCO2. Capnography is the preferred method of ETCO2 measurements in intubated children but should also be considered in spontaneously breathing children who for instance undergo deep procedural sedation or present in acute respiratory failure.72–76 High flow oxygen might lead to artificially lower ETCO2 values.77
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Source of support: This publication was made possible, in part, by Clinical and Translational Science Award Grant Nos. UL1 TR000142 and KL2 TR000140 from the National Center for Advancing Translational Science, components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.
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Clinical Trials Registration: Name: Using Capnography to Reduce Hypoxia During Pediatric Sedation, Registration No: NCT01463527.
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Presentations: Data were presented from this study in platform format at both the Eastern Society of Pediatric Research in Philadelphia, PA, March 2013, and the Pediatric Academic Society meeting in Washington, DC, May 2013.