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Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis
  1. Rhodri Saunders1,2,
  2. Michel M R F Struys3,4,
  3. Richard F Pollock2,
  4. Michael Mestek5,
  5. Jenifer R Lightdale6,7
  1. 1 Coreva Scientific GmbH & Co. KG., Freiburg, Germany
  2. 2 Ossian Health Economics and Communications, Basel, Switzerland
  3. 3 Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
  4. 4 Department of Anesthesia, Ghent University, Ghent, Belgium
  5. 5 Minimally Invasive Therapies Group, Medtronic, Boulder, Colorado, USA
  6. 6 Division of Pediatric Gastroenterology, UMass Memorial Children’s Medical Center, Westborough, Massachusetts, USA
  7. 7 Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  1. Correspondence to Richard F Pollock; pollock{at}


Objective To evaluate the effect of capnography monitoring on sedation-related adverse events during procedural sedation and analgesia (PSA) administered for ambulatory surgery relative to visual assessment and pulse oximetry alone.

Design and setting Systematic literature review and random effects meta-analysis of randomised controlled trials (RCTs) reporting sedation-related adverse event incidence when adding capnography to visual assessment and pulse oximetry in patients undergoing PSA during ambulatory surgery in the hospital setting. Searches for eligible studies published between 1 January 1995 and 31 December 2016 (inclusive) were conducted in PubMed, the Cochrane Library and EMBASE without any language constraints. Searches were conducted in January 2017, screening and data extraction were conducted by two independent reviewers, and study quality was assessed using a modified Jadad scale.

Interventions Capnography monitoring relative to visual assessment and pulse oximetry alone.

Primary and secondary outcome measures Predefined endpoints of interest were desaturation/hypoxaemia (the primary endpoint), apnoea, aspiration, bradycardia, hypotension, premature procedure termination, respiratory failure, use of assisted/bag-mask ventilation and death during PSA.

Results The literature search identified 1006 unique articles, of which 13 were ultimately included in the meta-analysis. Addition of capnography to visual assessment and pulse oximetry was associated with a significant reduction in mild (risk ratio (RR) 0.77, 95% CI 0.67 to 0.89) and severe (RR 0.59, 95% CI 0.43 to 0.81) desaturation, as well as in the use of assisted ventilation (OR 0.47, 95% CI 0.23 to 0.95). No significant differences in other endpoints were identified.

Conclusions Meta-analysis of 13 RCTs published between 2006 and 2016 showed a reduction in respiratory compromise (from respiratory insufficiency to failure) during PSA with the inclusion of capnography monitoring. In particular, use of capnography was associated with less mild and severe oxygen desaturation, which may have helped to avoid the need for assisted ventilation.

  • Capnography
  • Meta-analysis
  • Procedural sedation
  • Ambulatory surgery

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  • Contributors MM formulated the research question. RFP and RS devised the search strategy and data extraction protocol, which was critically reviewed and revised by MM, JRL and MMRFS. RFP and RS then conducted the literature searches, screening, data extraction and meta-analysis, and cowrote the manuscript. MM, JRL and MMRFS critically reviewed the manuscript and made substantive revisions prior to submission.

  • Funding This study was funded by Medtronic following a research proposal submitted by Ossian Health Economics and Communications GmbH. The sponsor reviewed the final manuscript prior to submission, but submission was not contingent on a particular outcome of the analysis.

  • Competing interests All authors have completed the Unified Competing Interest forms at (available on request from the corresponding author) and declare: MM is a full-time employee of Medtronic. RFP is a full-time employee of Ossian Health Economics and Communications GmbH, who received research and consultancy fees from Medtronic to conduct the literature review and meta-analysis and prepare the manuscript. RS was a full-time employee of Ossian Health Economics and Communications GmbH at the time of performing the meta-analysis and is currently a director of Coreva Scientific GmbH & Co. KG. MMRFS’s research group/department received grants and funding from The Medicines Company (USA), Masimo (USA), Fresenius (Germany), Acacia Design (The Netherlands), Medtronic (USA) and honoraria from The Medicines Company (USA), Masimo (USA), Fresenius (Germany), Baxter (USA), Medtronic (USA), Demed Medical (Belgium). JRL has served as a consultant for Medtronic and Norgine, and has received speaker honorarium from Mead Johnson and Perrigo.

  • Patient consent Not obtained.

  • Ethics approval No ethical approval was required for the study as all data were derived from published data; neither animal nor human subjects were enrolled as part of the present study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data used to derive the outcomes presented in the study are documented in the manuscript and supplementary materials. No additional data are therefore available.

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