end tidal CO2 for versed/fentanyl?

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Wow never heard of that ever being used for pain procedure sedation. However some places have an anesthesiologist soley for sedation and they may enploy it i suppose....
 
Never seen it. Overkill
 
My ASC is using this ASA guideline to try to force me to purchase one and use it.
http://www.asahq.org/For-Members/Clinical-Information/Standards-Guidelines-and-Statements.aspx

click on basic anesthesia monitoring

it says “3.2.4 During regional anesthesia (with no sedation) or local anesthesia (with no sedation), the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs. During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.”

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.”
 
does seem like it is overkill... sounds like they want you to buy them some equipment.

on the other hand, if it is an ASC, why dont they have etCO2 in each procedure room?

just do minimal sedation with versed alone. no need for etCO2.
 
they have end tidal CO2 in the OR but not in the pain procedure room. They either want me to move the conscious sedation patients into the OR (i'm at the mercy of the OR schedule cuz can't bump a surgeon to do one injection) or buy new equipment for the procedure room.
 
axm397 said:
they have end tidal CO2 in the OR but not in the pain procedure room. They either want me to move the conscious sedation patients into the OR (i'm at the mercy of the OR schedule cuz can't bump a surgeon to do one injection) or buy new equipment for the procedure room.
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Who's the person who decided to go tilting at windmills? An overzealeous nurse in the OR?

Ask for data to support the change in practice. If it aint broke...
 
believe it or not the anesthesiology group in charge of anesthesia in our ASC.

I told them I have a valid ACLS certification, double boarded in pain and PM&R, and have ran codes and intubated ppl.

I guess they're going to buy another useless $2000 equipment so I can say "positive end tidal CO2 waveform" on my note.

Dumb
 
Here's a thought: don't use sedation...... Gasp
 
We always use it but all rooms have anesthesia machines. Even before this recent change the sedation RN would hook up the cannula to the machine.

I think the hospital is working on ETCO2 for all PCA patients as well.
 
axm397 said:
believe it or not the anesthesiology group in charge of anesthesia in our ASC.

I told them I have a valid ACLS certification, double boarded in pain and PM&R, and have ran codes and intubated ppl.

I guess they're going to buy another useless $2000 equipment so I can say "positive end tidal CO2 waveform" on my note.

Dumb
Click to expand...

maybe they're encouraging you to give up and just order MAC for all your cases....
 
Jcm800 said:
yes.

this is why

it is not needed for IV sedation. it is for anesthesia.
Click to expand...


that comment opens a can of worms. technically, where does sedation end and anesthesia start?

from an anesthesiologist's standpoint, most if not all non-anesthesiologists do not have adequate training in airway management to be considered qualified, with the exception of ENT. also, ofttimes "moderate" sedation actually falls in the category of "deep" sedation or general anesthesia.
 
Ligament said:
Whos the ***** demanding this?
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CMS. We had a CMS audit this year and they were demanding that end tidal Co2 be used for sedation cases. Its completely ridiculous because now the ASC I do procedures at has had to buy special nasal cannulas with end tidal Co2 capabilities. These are more uncomfortable for patients and is a complete waste of money.

I would love to have a discussion with these CMS clowns regarding this. How about looking at the patient to see if they are breathing instead of staring at a monitor trying to document for end tidal co2 for someone getting 2 versed and 50 mcg of fentanyl.
 
why buy this equipment. During my training, we just taped a IV canula to the base of naris and attached the end of the catheter to the end tidal sampler tubing. Will cost you much less.
 
stim4u said:
why buy this equipment. During my training, we just taped a IV canula to the base of naris and attached the end of the catheter to the end tidal sampler tubing. Will cost you much less.
Click to expand...

I do the same when I do MAC cases with pts supine. CMS wanted an across the board policy switch for the ASC to "correct" the no end tidal situation. Not sure if taping iv cannula was discussed but that may be more positional and uncomfortable for patients when they are prone.
 
stim4u said:
why buy this equipment. During my training, we just taped a IV canula to the base of naris and attached the end of the catheter to the end tidal sampler tubing. Will cost you much less.
Click to expand...

or spike the IV canula through the NC, then cutt of the extra plastic... but it still just dumn and a waste of time
 
Ducttape said:
that comment opens a can of worms. technically, where does sedation end and anesthesia start?

from an anesthesiologist's standpoint, most if not all non-anesthesiologists do not have adequate training in airway management to be considered qualified, with the exception of ENT. also, ofttimes "moderate" sedation actually falls in the category of "deep" sedation or general anesthesia.
Click to expand...

"sedation" performed by an non anesthesia provider that gives 2 mg of versed and 50 mcg of fentanyl.
"anesthesia" is provided by an anesthesia provider who has done a pre-anesthesia H and P, assessed the ASA risk, and has risk stratified the patient,assessed airway class, uses standard ASA monitors (including ETCO2), fills out an anesthesia record, with an post-op anesthesia note and discharge, and then gives 2 mg of versed and 50 mcg of fentanyl.
 
Jcm800 said:
"sedation" performed by an non anesthesia provider that gives 2 mg of versed and 50 mcg of fentanyl.
"anesthesia" is provided by an anesthesia provider who has done a pre-anesthesia H and P, assessed the ASA risk, and has risk stratified the patient,assessed airway class, uses standard ASA monitors (including ETCO2), fills out an anesthesia record, with an post-op anesthesia note and discharge, and then gives 2 mg of versed and 50 mcg of fentanyl.
Click to expand...

yes, but when the patient seizes from bupiv toxicity, or gets a high spinal because some pain doc is silly enough to use lidocaine in his epidural... who do you want to intubate the patient, someone who has adequately and appropriately assessed an airway, or someone who thinks the airway is just the path to the upper esophageal sphincter?
 
SSdoc33 said:
Here's a thought: don't use sedation...... Gasp
Click to expand...

yeah - I do most of my cases with no sedation. i have done 3 "IV sedation cases" in the past year so I do most of my cases without any IV sedation. I have maybe 25% of patients who get oral anxiolytic (low dose benzo) - mostly RFAs, etc..

A couple weeks ago I had a patient who demanded IV sedation so I tried to schedule it and they told me about this "new rule" and told me I had to do it in the OR and have an anesthesiologist administer the sedation. Then the surgeon that they had to bump for my stupid little injection got pissed.... and so on and so forth....
 
The rules say a "qualitative monitor of CO2" no quantitative.......an ETCO2 monitor is both which is nice but could you put a facemask on a pt, watch the condensation and pts breathing and call that an adequate qualitative monitor of ETCO2? I do it all the time for my endoscopies where we don't have ETCO2 monitors and any well trained anesthesiologist should be able to do the same. A simple color change ET monitor would also work instead of a fancy digital ETCO2 monitor. W/that being said, ETCO2 IMO is one of the best monitors to have and well worth the investment.

And to clear up any confusion, MAC is considered any sedation given by anesthesiologist that isn't general anesthesia. It's simply a billing term that includes light, moderate, and deep sedation so that we can actually get paid for the services we are providing

that comment opens a can of worms. technically, where does sedation end and anesthesia start?
Click to expand...

The different levels of sedation refer to the types of stimuli the pt will respond to. When a pt will only respond to painful stimulii, it is considered deep sedation, if they will no longer respond to painful stimulii they are considered to be under general anesthesia.

The link below is the ASA statement on what constitutes different levels of sedation in more detail than I can remember. Hope this clears up any confusion
 

Attachments

Ducttape said:
yes, but when the patient seizes from bupiv toxicity, or gets a high spinal because some pain doc is silly enough to use lidocaine in his epidural... who do you want to intubate the patient, someone who has adequately and appropriately assessed an airway, or someone who thinks the airway is just the path to the upper esophageal sphincter?
Click to expand...

I am saying that for our practical purposes, you don't an anesthesiologist to give 2 of versed and 50 mcg of fentanyl. I AM an anesthesiologist, and I don't use bupivicaine in an epidural, I barely even use lidocaine in it. So I don't think they are gonna seize. I am stating the difference between when a non-anesthesia provider gives versed and an anesthesiologist does, that's all. The question is what is the difference between "anesthesia" and "sedation" it's the training one guy giving the versed.
 
agree with that, Jcm. thought you were being condescending about the benefits of having an anesthesiologist provide MAC.

we all know what, for example, a cardiologist or GI states is light or moderate sedation is often much more.

i dont think condensation itself qualifies for a marker of etCO2. are you truly watching CO2, or water moisture? the single use etCO2 does not turn always negative when there is no etCO2. so that might not qualify.
 
Jcm800 said:
I am saying that for our practical purposes, you don't an anesthesiologist to give 2 of versed and 50 mcg of fentanyl. I AM an anesthesiologist, and I don't use bupivicaine in an epidural, I barely even use lidocaine in it. So I don't think they are gonna seize. I am stating the difference between when a non-anesthesia provider gives versed and an anesthesiologist does, that's all. The question is what is the difference between "anesthesia" and "sedation" it's the training one guy giving the versed.
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JCM-

I'm an anesthesiologist as well. For epidurals I do on occasion put Bupivicaine in the epidural. Usually it's like 1ml of 0.25% Bupi, mixed with 2ml of PF NS and 80mg of depomedrol.


I highly doubt that anyone will seize with that small amount of bupi. In the cervical spine I dont use Bupi at all, or may consider 0.5ml of 1% lido plus 3ml of NS and 80mg of depomedrol.

I dont think in pain medicine, we use doses of bupi or lido or any local aneshtic to cause a seizuere. Now, injecting into the vertebral artery when doing a stellate is a totally different can of worms.
 
docnyc said:
CMS. We had a CMS audit this year and they were demanding that end tidal Co2 be used for sedation cases. Its completely ridiculous because now the ASC I do procedures at has had to buy special nasal cannulas with end tidal Co2 capabilities. These are more uncomfortable for patients and is a complete waste of money.

I would love to have a discussion with these CMS clowns regarding this. How about looking at the patient to see if they are breathing instead of staring at a monitor trying to document for end tidal co2 for someone getting 2 versed and 50 mcg of fentanyl.
Click to expand...



Very interesting and very ridiculous.....does the ER also need to have end tidal CO2 monitors... obviously they are giving fentanyl and versed. What about the floor and ICU?


Then the first thing out of their mouth is "30-40 cents of every medical dollar is wasted"
 
axm397 said:
My ASC is using this ASA guideline to try to force me to purchase one and use it.
http://www.asahq.org/For-Members/Clinical-Information/Standards-Guidelines-and-Statements.aspx

click on basic anesthesia monitoring

it says “3.2.4 During regional anesthesia (with no sedation) or local anesthesia (with no sedation), the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs. During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.”

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.”
Click to expand...



why do they expect you to buy it? when have physicians been responsible for capital equipment purchases?
 
PinchandBurn said:
JCM-

I'm an anesthesiologist as well. For epidurals I do on occasion put Bupivicaine in the epidural. Usually it's like 1ml of 0.25% Bupi, mixed with 2ml of PF NS and 80mg of depomedrol.


I highly doubt that anyone will seize with that small amount of bupi. In the cervical spine I dont use Bupi at all, or may consider 0.5ml of 1% lido plus 3ml of NS and 80mg of depomedrol.

I dont think in pain medicine, we use doses of bupi or lido or any local aneshtic to cause a seizuere. Now, injecting into the vertebral artery when doing a stellate is a totally different can of worms.
Click to expand...

i assume you do not do lumbar sympathetic blocks or celiac/hypogastric plexus blocks?
 
I was also approached by anesthesia in our hospital, letting me know they felt the gold standard was ETCO2 monitoring for IV sedation with pain procedures. Except for a few legacy patients, we've moved to small 1x oral benzo prior to procedure.
 
pmrrmp said:
I was also approached by anesthesia in our hospital, letting me know they felt the gold standard was ETCO2 monitoring for IV sedation with pain procedures. Except for a few legacy patients, we've moved to small 1x oral benzo prior to procedure.
Click to expand...

Just one more reason not to do IV sedation on 95% of your patients.
 
Ducttape said:
i assume you do not do lumbar sympathetic blocks or celiac/hypogastric plexus blocks?
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Ok I will give you that. When doing those and Stellates, it is a concern.

Your assumption is correct, I dont do a whole lot of celiac/hypogastric blocks. I dont have many cancer pain pts. I probably wouldnt do them for non-malig pain, because I would not consider doing neurolysis in non-malginant pain.

But I'm talking bread and butter cases,stim,etc. Chances are negligible.
 
drusso said:
We use ETCO2 in our office procedure room with sedation cases. It measures it off a nasal cannula set-up. Not too expensive. Works well.
Click to expand...



Does it work ..........YES

Does it need to be manditory for 100% of pain cases given with IV sedation............NO


This is simply a solution without a problem.
 
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