Monitoring End-tidal CO2

[drlee]

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I have a debate with a colleague of mine. I say monitoring end-tidal CO2 is not considered a standard ASA monitor. He says it is. Can anyone resolve this dispute? I have a case of Guinness at stake! 😕

 

[proman]

STANDARDS FOR BASIC ANESTHETIC MONITORING
Committee of Origin: Standards and Practice Parameters
(Approved by the ASA House of Delegates on October 21, 1986, and last amended on
October 25, 2005)

http://www.asahq.org/publicationsAndServices/standards/02.pdf


VENTILATION
OBJECTIVE
To ensure adequate ventilation of the patient during all anesthetics.
METHODS
l) Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful. Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment. Quantitative monitoring of the volume of expired gas is strongly encouraged.*
2)
When an endotracheal tube or laryngeal mask is inserted, its correct positioning must be verified by clinical assessment and by identification of carbon dioxide in the expired gas. Continual end-tidal carbon dioxide analysis, in use from the time of endotracheal tube/laryngeal mask placement, until extubation/removal or initiating transfer to a postoperative care location, shall be performed using a quantitative method such as capnography, capnometry or mass spectroscopy.* When capnography or capnometry is utilized, the end tidal CO2 alarm shall be audible to the anesthesiologist or the anesthesia care team personnel.*
3) When ventilation is controlled by a mechanical ventilator, there shall be in continuous use a device that is capable of detecting disconnection of components of the breathing system. The device must give an audible signal when its alarm threshold is exceeded.
4) During regional anesthesia and monitored anesthesia care, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and/or monitoring for the presence of exhaled carbon dioxide.

 

[snowman8]

I think you better hit up your local liquor store!

 

[coprolalia]

More piling on...

The plaintiff claimed that the hospital was negligent in not providing CO2 monitoring equipment that would have alerted the anesthesiologist that the nurse anesthetist had placed the tube in the esophagus rather than the trachea. The court of appeals upheld the finding that failure to use CO2 monitors violated the national standard of care as of late 1987 based upon evidence that CO2 monitors were 1) generally available in 1985; 2) frequently used by teaching hospitals in 1986; 3) characterized as “an emerging standard of care” in an August 1986 Journal of the American Medical Association (JAMA) article; and 4) recommended by the ASA “Standards for Basic Anesthesia Monitoring”

http://www.asahq.org/Newsletters/2002/2_02/kragie0202.htm

-copro

 

[VentdependenT]

Its in the back of baby miller too. That's where I first read it as a CA-0.

 

[leviathan]

Why would you ever think end-tidal CO2 monitoring is not an absolute necessity when monitoring someone's ventilation? Don't take that as an attack on you...I'm just a lowly med student, and maybe I'm overinflating its importance in my mind.

 

[huktonfonix]

Why would you ever think end-tidal CO2 monitoring is not an absolute necessity when monitoring someone's ventilation? Don't take that as an attack on you...I'm just a lowly med student, and maybe I'm overinflating its importance in my mind.

Noone said that its an ABSOLUTE NECESSITY. Its not. It is part of the ASA standard monitors. Its simply an additional tool used with other clinical monitors and data that will contribute to a safe anesthetic for the patient. Other clinical data such as breath sounds, chest/air movement, need to be used sometimes even though it may not be optimal.

 

[leviathan]

Noone said that its an ABSOLUTE NECESSITY. Its not. It is part of the ASA standard monitors. Its simply an additional tool used with other clinical monitors and data that will contribute to a safe anesthetic for the patient. Other clinical data such as breath sounds, chest/air movement, need to be used sometimes even though it may not be optimal.

That's true. Would you be able to defend yourself in court from a misplaced tube if you documented all those things, but not a positive + continuous EtCO2 waveform reading? I agree it's not necessarily required on every case, but I'm trying to see things from a medicolegal / CYA point of view.

 

[huktonfonix]

nope. If you have CO2 monitoring equipment available, it should be used. However, there will be many times when you wont have CO2 monitoring equipment available and you'd better be able to tell if a patient is ventilating or not without it.

 

[drccw]

STANDARDS FOR BASIC ANESTHETIC MONITORING
Committee of Origin: Standards and Practice Parameters
(Approved by the ASA House of Delegates on October 21, 1986, and last amended on
October 25, 2005)

http://www.asahq.org/publicationsAndServices/standards/02.pdf


VENTILATION
OBJECTIVE
To ensure adequate ventilation of the patient during all anesthetics.
METHODS
l) Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful. Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment. Quantitative monitoring of the volume of expired gas is strongly encouraged.*
2)
When an endotracheal tube or laryngeal mask is inserted, its correct positioning must be verified by clinical assessment and by identification of carbon dioxide in the expired gas. Continual end-tidal carbon dioxide analysis, in use from the time of endotracheal tube/laryngeal mask placement, until extubation/removal or initiating transfer to a postoperative care location, shall be performed using a quantitative method such as capnography, capnometry or mass spectroscopy.* When capnography or capnometry is utilized, the end tidal CO2 alarm shall be audible to the anesthesiologist or the anesthesia care team personnel.*
3) When ventilation is controlled by a mechanical ventilator, there shall be in continuous use a device that is capable of detecting disconnection of components of the breathing system. The device must give an audible signal when its alarm threshold is exceeded.
4) During regional anesthesia and monitored anesthesia care, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and/or monitoring for the presence of exhaled carbon dioxide.[/quote]

Depends on the case. ASA standard? for a GA it sounds like... but there are a lot of cases that are done not under GA... spinal anesthetics? some people pop a mask on and monitor etCO2... but it seems adequate (per teh ASA) to monitor via observation... likewise during MAC....

If I do a MAC, I tend to not monitor ETCO2 (especially over in endo where we dont have it available) unless they are under the drapes (ie port placement)

So the long and short of it is, I dont think you owe your buddy a case... but I am not sure if he owes you one either...