Your way of monitoring ETCO2

[hyperecho]

How many of you are routinely monitoring ETCO2 during a MAC?

How do you monitor ETCO2 during a MAC? I have seen or used (1) ETCO2 nasal cannula with and without a piece covering the mouth, (2) Angiocath attached to sample line inserted into the nose, mouth, oral airway or mask. We haven't tried any of the available ETCO2 masks.

Anyone have any tricks or experience with any of the ETCO2 masks on the market? Is there any you would recommend?

With electronic anesthesia records we can no longer just write "+" in the box.

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[BobBarker]

Get some co2 line monitoring cable. Pull off the end using brute strength. Insert naked end into hole on side of face mask. No need for the angiocath which in my experience is more likely to slip out anyways. This allows you if you need to mask to just rehook up the etco2 connected to the circuit.

 

[Yangkower]

We use the nasal cannula with the ETCO2 monitor. Or you can use a facemask and stick the ET sampling line inside. The angiocath technique is OK but i find it tends to get kinked and i end up fiddling with it the whole case.

 

[urge]

How many of you are routinely monitoring ETCO2 during a MAC?

Is that trick question?

You know the answer is 100%.

 

[hyperecho]

Is that trick question?

You know the answer is 100%.

No, not a trick question. I imagine the official answer is 100% like you say but I'm looking for what people are actually doing in their practice.

My experience from residency, academic practice and private practice is that ETCO2 was not routinely monitored for every MAC case. I try to monitor ETCO2 for the cases I do but have seen plenty of others not monitor ETCO2 during a MAC. Seems like your experience has been different than mine.

What device or trick do you use that works 100% of the time?

 

[partydoc]

If you take a face mask and cut 2 of those small holes on the side, the end of the CO2 monitor fits in pretty snug. No need to pull the top off either.

 

[pgg]

No, not a trick question. I imagine the official answer is 100% like you say but I'm looking for what people are actually doing in their practice.

For anesthesiologists, use of capnography is the unequivocal standard of care for moderate sedation (aka "conscious sedation") and anything deeper.

This is the July 2011 ASA standard: https://www.asahq.org/For-Members/~...s Stmts/Basic Anesthetic Monitoring 2011.ashx

Unless the patient has a normal response to just verbal stimulation, capnography isn't optional (there's an exception in the standard if circumstances or the procedure prohibit its use).


Usually I'll just tuck the sample line under the O2 facemask or tape it to the nasal cannula. If I'm especially motivated I might use a clipped angiocath as a connector.

 

[hyperecho]

Thank you for your response.

I'm familiar with the ASA guidelines. I'm not questioning the guidelines or the utility of ETCO2 monitoring; as I am an advocate of ETCO2 monitoring for every moderate or deep sedation case. I'm asking to learn from the experience of others so I can improve our clinical practice. I have tried all of the techniques mentioned so far, with the exception of ripping the end of the CO2 sample line off : ).

In my current practice, we do a large number blocks plus Propofol sedation cases. I am trying to encourage wider use of of ETCO2 for these cases. We are looking at several commercially available devices for our practice and was hoping to get some feedback on them.

 

[Gastrapathy]

I watch anesthesia providers spend more time f-ing with the etco2 cannula than doing anything else in the case now. It may be policy but the technology isn't up to the policy and I think it keeps people from watching the patient. It also adds 10 bucks a case in disposables. I get it for deep sedation cases but I think the multisociety GI position paper from last year is right. Also totally distracts sedation nurses (omg he's not breathing...BREATHE.... Umm look at him, he's wide awake). This is my experience at about 4 endo centers and hospitals. It gets abandoned halfway thru more than half the time.


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[hyperecho]

I watch anesthesia providers spend more time f-ing with the etco2 cannula than doing anything else in the case now. It may be policy but the technology isn't up to the policy and I think it keeps people from watching the patient. It also adds 10 bucks a case in disposables. I get it for deep sedation cases but I think the multisociety GI position paper from last year is right. Also totally distracts sedation nurses (omg he's not breathing...BREATHE.... Umm look at him, he's wide awake). This is my experience at about 4 endo centers and hospitals. It gets abandoned halfway thru more than half the time.

I have definitely experienced the frustration of trying to get a good ETCO2 waveform. Sometimes I spend the entire time I'm giving a lunch break trying to get a waveform. After a certain point it turns into a personal challenge

I totally agree with you about using common sense. However, we are concerned that going to an electronic anesthesia record, not having consistent ETCO2 reading could be an issue with future JCAHO visits

 

[urge]

The pre made split nasal cannulas(one nostril for oxygen, one for monitoring) don't work very well, so don't bother with those.

Rigging a regular cannula with an angiocath doesn't work well either.

I have seen ads for some nasal cannulas that have little "legs" protruding into the mouth that seem to me should work better, even if the patient is a mouth breather. I have no experience with them though.

 

[hyperecho]

The pre made split nasal cannulas(one nostril for oxygen, one for monitoring) don't work very well, so don't bother with those.

Rigging a regular cannula with an angiocath doesn't work well either.

I have seen ads for some nasal cannulas that have little "legs" protruding into the mouth that seem to me should work better, even if the patient is a mouth breather. I have no experience with them though.

I haven't had much success with the split nasal cannulas either.

In your earlier post you said you monitor ETCO2 for 100% of your cases. Is there something you are doing or using that works 100% of the time or do you attempt 100% of time but aren't successful 100% of the time?

This looks similar to the one with the leg that goes into the mouth. Anyone have experience with this type of ETCO2 nasal cannula?

View attachment 184821

 

[urge]

100% attempt. 20% success. We have had electronic record for a long time and hasn't been an issue as long as you don't box the patient.

My recommendation is not to box the patient regardless of how the anesthesia record ends up looking.

 

[Gastrapathy]

The problem with this approach is that it assumes you are rational. That ignores the other people who sedate patients.

If it is a requirement, nurses can measure it, freak out about it, write policies about it and make checkboxes on clipboards about it. I think your society has screwed us all by making it a requirement when the current technology works 20% of the time.


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[urge]

I have been considering a transtrachial angiocath.

 

[hyperecho]

I have been considering a transtrachial angiocath.

Brilliant idea, but a tough consent to obtain.

 

[Spinach Dip]

I have been considering a transtrachial angiocath.

I like this way of thinking.

 

[RxBoy]

1) Easiest way is NC with distal side port. Takes a second to attach.

2) If youre doing a really a long deep sedation, pop off end gas sample line and weave through side facemask holes couple times and have it end near where the mouth will be. It wont ever come loose and much more accurate as its being sampled near the mouth.

3) Small trick if they are coming with a standard NC, just attach end directly to d-fend unit. It will fit snugly depending on manufacture of NC. Then just throw O2 mask on top. When ur down just take off mask and ship back with NC in place.

4) If you want a pretty accurate capnograph waveform, just shut off O2 flow for a couple breathes and the number will be pretty accurate. Usually its being diluted by the mixing of fresh O2.

5) However the quickiest monitor is the back of you hand. If you think theyre not exchanging, feel for the mist. If its there, theyre breathing.

 

[Random Anesthesiologist]

I place silk tape that come down over the nose with the etco2 monitor stuck to it, then bring the blanket covering them up to their nose. I have had no trouble capturing waveforms.

Some attendings do it different ways if they set up while I'm on a break or something. I've seen the angiocath in the face mask or the special nasal cannula. I like my way best, .

 

[BuzzPhreed]

RASCAL tube end w/ or w/out angiocath. In the nose. Done. Cheaper than these ridiculously expensive "special" nasal cannulas that they charge $14-16 a pop for.

 

[hyperecho]

Anyone have experience with the ETCO2 masks availabl on the market?

 

[PonyUp]

I haven't had issues [yet] with the angocath+facemask. Snip the angiocath, wedge it in side hole of facemask. It doesn't involve tape, the seal from the mask aids in a consistent waveform, and the ETCO2 stays consistent enough regardless of whether it is factual. Pair that with the fact that we're taking them out to PACU with the same facemask+O2 tubing, and the net cost of your monitor is a 20g angiocath.

That, and deep down inside everyone is a mouthbreather.

 

[deleted162650]

Most of the time I use the angiocath technique already described and I haven't had any of the problems others mention. In some of our rooms we stock Southmedic "Capnoxygen" masks which have worked quite well for me.

 

[jwk]

I watch anesthesia providers spend more time f-ing with the etco2 cannula than doing anything else in the case now. It may be policy but the technology isn't up to the policy and I think it keeps people from watching the patient. It also adds 10 bucks a case in disposables. I get it for deep sedation cases but I think the multisociety GI position paper from last year is right. Also totally distracts sedation nurses (omg he's not breathing...BREATHE.... Umm look at him, he's wide awake). This is my experience at about 4 endo centers and hospitals. It gets abandoned halfway thru more than half the time.


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You have an iPhone 6?!?

No offense intended, but standard of care for GI and "sedation nurses" vs anesthesiology sounds quite different. You might get by without EtCO2 monitoring, but for us, it's not optional.

We monitor EtCO2 using several different types MAC nasal cannulas. All do a decent job. I don't care about the number - I want to see a respiratory waveform of some sort. We do it on EVERY MAC case we do.

Wonder if they were using one with Joan Rivers?

 

[Gastrapathy]

No but you win the prize for being observant. I just think the "sent from my" thing is annoying so I always change it to something ridiculous.

 

[gassyPants]

Last week I took over a CRNA lithotripsy room and discovered they'd been using cut filter needles (for drawing up medications from glass vials), and adopted the practice for the rest of the day. They fit in the holes of the face mask much more tightly than the angiocaths.

Any tricks for when the patient is face down? I did a bunch of prone kyphoplasties last month under sedation. We used the nasal cannulas with the built-in EtCO2, but when they fell out of place/the patient was a mouth breather all I really had left was the pulse ox which made my stomach churn. Luckily, the surgeon was crazy fast.

 

[dhb]

I've never used an etco2 monitoring for an endoscopy and quite frankly i don't know why i would need it

 

[anes]

I cut a monoject needleless med prep cannula at the hub. Stick it through the hole on the side of a facemask. Screw in the co2 sampling line. It fits perfectly, and is very difficult to remove once placed. I've never had an issue with it falling iut . and its pretty impossible to kink.