new ASA monitoring standard

[Monty Python]

Was wondering if anyone's hospital plans to install ETCO2 monitors everywhere sedation is given (ER, Xray, endo, etc)? How are folks interpreting section 3.2.4 of the revised ASA standards for basic anesthetic monitoring, which take effect July 1: http://www.asahq.org/For-Healthcare...s Stmts/Basic Anesthetic Monitoring 2011.ashx



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[PMPMD]

Was wondering if anyone's hospital plans to install ETCO2 monitors everywhere sedation is given (ER, Xray, endo, etc)? How are folks interpreting section 3.2.4 of the revised ASA standards for basic anesthetic monitoring, which take effect July 1: http://www.asahq.org/For-Healthcare...s Stmts/Basic Anesthetic Monitoring 2011.ashx

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 20, 2010 with an effective date of July 1, 2011)

These standards apply to all anesthesia care although, in emergency circumstances, appropriate life support measures take precedence. These standards may be exceeded at any time based on the judgment of the responsible anesthesiologist. They are intended to encourage quality patient care, but observing them cannot guarantee any specific patient outcome. They are subject to revision from time to time, as warranted by the evolution of technology and practice. They apply to all general anesthetics, regional anesthetics and monitored anesthesia care. This set of standards addresses only the issue of basic anesthetic monitoring, which is one component of anesthesia care. In certain rare or unusual circumstances, 1) some of these methods of monitoring may be clinically impractical, and 2) appropriate use of the described monitoring methods may fail to detect untoward clinical developments. Brief interruptions of continual† monitoring may be unavoidable. These standards are not intended for application to the care of the obstetrical patient in labor or in the conduct of pain management.

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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.

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I don't believe these standards apply to sedation given when anesthesiologists aren't present. I don't think the ASA has authority to regulate sedation given by other specialties in the absence of anesthesia providers.

 

[Monty Python]

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 20, 2010 with an effective date of July 1, 2011)

These standards apply to all anesthesia care although, in emergency circumstances, appropriate life support measures take precedence. These standards may be exceeded at any time based on the judgment of the responsible anesthesiologist. They are intended to encourage quality patient care, but observing them cannot guarantee any specific patient outcome. They are subject to revision from time to time, as warranted by the evolution of technology and practice. They apply to all general anesthetics, regional anesthetics and monitored anesthesia care. This set of standards addresses only the issue of basic anesthetic monitoring, which is one component of anesthesia care. In certain rare or unusual circumstances, 1) some of these methods of monitoring may be clinically impractical, and 2) appropriate use of the described monitoring methods may fail to detect untoward clinical developments. Brief interruptions of continual† monitoring may be unavoidable. These standards are not intended for application to the care of the obstetrical patient in labor or in the conduct of pain management.

...

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.

###

I don't believe these standards apply to sedation given when anesthesiologists aren't present. I don't think the ASA has authority to regulate sedation given by other specialties in the absence of anesthesia providers.

How does that jive with: http://sedationcertification.com/20...esthesiologists-must-balance-jcaho-standards/

"JCAHO further mandates that sedation practices throughout the hospital be monitored and evaluated by the Department of Anesthesia."

Wouldn't that make all sedation (regardless of provider) fall under ASA monitoring standards?

 

[PMPMD]

How does that jive with: http://sedationcertification.com/20...esthesiologists-must-balance-jcaho-standards/

"JCAHO further mandates that sedation practices throughout the hospital be monitored and evaluated by the Department of Anesthesia."

Wouldn't that make all sedation (regardless of provider) fall under ASA monitoring standards?

Touche'

 

[IlDestriero]

Was wondering if anyone's hospital plans to install ETCO2 monitors everywhere sedation is given (ER, Xray, endo, etc)? How are folks interpreting section 3.2.4 of the revised ASA standards for basic anesthetic monitoring, which take effect July 1: http://www.asahq.org/For-Healthcare...s Stmts/Basic Anesthetic Monitoring 2011.ashx



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We already have it everywhere, including on the majority of our transport monitors.

 

[pgg]

Was wondering if anyone's hospital plans to install ETCO2 monitors everywhere sedation is given (ER, Xray, endo, etc)?

Yes.

Well, sort of - we're getting portable monitors that we can take with us, or that the 'sedation service' nurses can take with them. Since the anesthesia dept got conned into administering the whole sedation nurse thing, they'll use it too.

I have no idea what they're doing down in ER-land or elsewhere that we aren't involved.

 

[jwk]

We're ordering a bunch of new EtCO2-capable monitors or add-ons. GI cases, radiology, cardioversions and AICD tests, podiatry - every place that WE do sedation and MAC cases will need monitoring, regardless of length of the procedure (sucks for those 30 sec cardioversions).

 

[tucker27705]

I'm not in favor of this new standard. I understand the value when the pt is intubated. But when not intubated it tells you very little other than the pt is moving air. How much air is the real question, and ETCO2 doesn't answer that. I think it will instill a false confidence in providers who see ETCO2 on the monitor. I would prefer my anesthetists lookk at the patient and evaluate ventilation based on chest excursion etc. Of course ETCO2 can be valuable info, but not if it causes the provider to ignore other information--and I'm afraid it will.
What do you guys think?
Tuck

 

[rsgillmd]

I'm not in favor of this new standard. I understand the value when the pt is intubated. But when not intubated it tells you very little other than the pt is moving air. How much air is the real question, and ETCO2 doesn't answer that. I think it will instill a false confidence in providers who see ETCO2 on the monitor. I would prefer my anesthetists lookk at the patient and evaluate ventilation based on chest excursion etc. Of course ETCO2 can be valuable info, but not if it causes the provider to ignore other information--and I'm afraid it will.
What do you guys think?
Tuck

You make a good point Tuck. Your comments reminds me of a situation that occurred during residency.

Part of our PACU was (and probably still is) used to recover cardiac surgery patients when the CTICU gets full. I was hanging out waiting for another case to get started when I heard a ruckus. A patient had self extubated. I could tell from 2 feet away that he was not moving air. I quickly got to the head of the bed, confirmed no air movement and unresponsiveness, grabbed the ambu bag and started ventilating while instructing the nurses to open the nearby airway box. Their reply: "But his pulse ox is 100%" My reply: "It doesn't matter. He's not moving air." The nurse was struggling with the blade on the laryngoscope, so I grabbed it and put it together myself. Even as I was doing this I heard again "But his pulse ox is 100%" The pulse ox finally started to go down after I had placed the tube and was ready to ventilate.

The moral of the story: The CTICU nurses were fooled by a reassuring pulse ox value and were not looking at their patient.

What I foresee in the future is exactly what you are predicting: someone will see a series of small bumps in the EtCO2 and say the person is breathing, but won't take into account the quality of the air exchange.

However, I have also seen people fooled by upper airway obstruction when they see some chest movement but the neck is collapsing and there is no exchange if you feel by the mouth/nose. So this EtCO2 monitor will hopefully add another check into that scenario.

Long story short, in my opinion, in the end there is no substitute for good clinical training and judgment.

 

[pgg]

Just as people have to be taught that the number on the pulse ox lags reality, they'll have to be taught that bumps on the capnograph might not guarantee adequate MV.

I don't see a downside other than equipment cost, and god knows every place I've ever worked has blown more money on less useful stuff.

 

[cchoukal]

At my place, we're able to have an anesthesia machine (and, hence, EtCO2) at all of our anesthetizing/sedation locations. The one exception had always been when we do ECT in the PACU. We purchased modules to plug into existing monitors and it works just fine. I assume the modules were not cheap, but our facility interpreted the new guidelines as "thou shalt have EtCO2."

 

[Hamhock]

At my place, we're able to have an anesthesia machine (and, hence, EtCO2) at all of our anesthetizing/sedation locations. The one exception had always been when we do ECT in the PACU. We purchased modules to plug into existing monitors and it works just fine. I assume the modules were not cheap, but our facility interpreted the new guidelines as "thou shalt have EtCO2."

In the ED also?

HH

 

[jwk]

Just as people have to be taught that the number on the pulse ox lags reality, they'll have to be taught that bumps on the capnograph might not guarantee adequate MV.

I don't see a downside other than equipment cost, and god knows every place I've ever worked has blown more money on less useful stuff.

We're "the people". The standard is for US to use them during MAC and sedation cases. We're already using them in the OR - it's not like any of us need re-training to learn how to use them in a non-OR setting.

With the "MAC nasal cannulas" we're looking as much for the presence of a respiratory waveform as anything else. The number doesn't mean as much in an open system.

 

[cchoukal]

In the ED also?

HH

The ED isn't bound by the Asa standards and I'm not sure what they're doing, if anything, about the new language.

 

[pgg]

We're "the people".

Maybe not.

As trinityalumnus mentions upthread, JCAHO requires all sedation in the hospital to be monitored by the anesthesia department.

Here, all of the sedation-qualified nurses in the hospital belong to the anesthesia department, to the point that when a clinic needs to schedule sedation for something, they come to us and we provide a sedation nurse.

My interpretation is that those nurses need to be using ETCO2 as of July 2011. Maybe this is an excessively conservative interpretation, but it's what we're doing.



Also, just as some anesthesia departments have leveraged that JCAHO role into committee/pharmacy/policy maneuvers to get propofol banned from ERs, I don't think it's at all a stretch that such maneuvers will be made to force ERs to start using ETCO2. Right or wrong, I think this is what's going to happen, so I don't think it's just us.

 

[Mman]

Maybe not.

As trinityalumnus mentions upthread, JCAHO requires all sedation in the hospital to be monitored by the anesthesia department.

Here, all of the sedation-qualified nurses in the hospital belong to the anesthesia department, to the point that when a clinic needs to schedule sedation for something, they come to us and we provide a sedation nurse.

My interpretation is that those nurses need to be using ETCO2 as of July 2011. Maybe this is an excessively conservative interpretation, but it's what we're doing.



Also, just as some anesthesia departments have leveraged that JCAHO role into committee/pharmacy/policy maneuvers to get propofol banned from ERs, I don't think it's at all a stretch that such maneuvers will be made to force ERs to start using ETCO2. Right or wrong, I think this is what's going to happen, so I don't think it's just us.

JCAHO might state that the Dept of Anesthesia needs to monitor sedation in the hospital, it doesn't state that it all needs to fall under the ASA guidelines and standards.

 

[pgg]

JCAHO might state that the Dept of Anesthesia needs to monitor sedation in the hospital, it doesn't state that it all needs to fall under the ASA guidelines and standards.

What guideline or standard do you think JCAHO expects the anesthesia department to use when monitoring sedation in the hospital? (Here, we the anesthesia department write the policy, and we refer to our own standard of care.)

Not trying to be a smartass or anything, and again I realize our position is over on the conservative side.

But it's like when the ER guys come in here and ask us about propofol or etomidate for "procedural sedation" in the ER. When it comes to GA on a full stomach, which is what they're usually doing, the only answer we can possibly give them is one grounded in our own standard of care. Likewise, when it comes to the monitoring standards for sedation that we're supposed to be supervising or monitoring per JCAHO, I think the only defensible answer we can give is similarly grounded in our own standard of care.

And that standard of care, as of 7/2011, is indisputably to use ETCO2 monitoring for any moderate or deep sedation.

Anesthesia-influenced hospital committees have taken propofol away from ERs all over the place, on the strength of a phrase in the package insert and this JCAHO requirement. It doesn't seem any less reasonable for there to be similar pressure from anesthesia to push CO2 monitoring on everyone in sight.



As for my specific situation here, we train and certify all of the sedation nurses. Their "cases" are scheduled through us. We own them, and we feel obligated to give them the same monitoring tools that we would use. As of 7/2011 that will include ETCO2.

 

[Marygfullerton]

Just an RN trying to comply with ETCO2 monitoring during CS cases... Any word from anyone on how to monitor during bronchoscopy cases when pulmonologist uses the nares for the scope and goes through a face mask with a hole cut in it? Can you please advise?

 

[IlDestriero]

Just an RN trying to comply with ETCO2 monitoring during CS cases... Any word from anyone on how to monitor during bronchoscopy cases when pulmonologist uses the nares for the scope and goes through a face mask with a hole cut in it? Can you please advise?

I'm not 100% sure I understand what they're doing, but if you have an O2 mask on you can put a trimmed 16 g IV through one of the side holes in the mask and hook the ET CO2 tubing to the IV. It won't give you a number that you can follow, but it should catch enough CO2 to give you a reading.
Cheers!

 

[Bertelman]

Just an RN trying to comply with ETCO2 monitoring during CS cases... Any word from anyone on how to monitor during bronchoscopy cases when pulmonologist uses the nares for the scope and goes through a face mask with a hole cut in it? Can you please advise?

If it's one of the standard face masks with little vent holes on the side, they happen to accommodate an 18 g IV cath quite well, which by chance attaches to the CO2 sampling line.

 

[urge]

Was wondering if anyone's hospital plans to install ETCO2 monitors everywhere sedation is given (ER, Xray, endo, etc)? How are folks interpreting section 3.2.4 of the revised ASA standards for basic anesthetic monitoring, which take effect July 1: http://www.asahq.org/For-Healthcare...s Stmts/Basic Anesthetic Monitoring 2011.ashx



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Considering that CA 2, 3, and fellows tell me all the time the patent is breathing well, even though they are totally obstructed & soon to leave hospital in a body bag, I would say the ETCO2 pays for itself.

Since good providers are few and hard to find, I would say put the machine everywhere.

 

[MRW]

Long story short, in my opinion, in the end there is no substitute for good clinical training and judgment.

Hear Hear

Is not a vigilant anesthesia provider an ASA monitor?

 

[cincincyreds]

We only get an etco2 monitor for tee when Jcaho is in the hospital. Yes, I am not kidding about this. The upper levels in the group don't want to spend any money.

 

[Mman]

Considering that CA 2, 3, and fellows tell me all the time the patent is breathing well, even though they are totally obstructed & soon to leave hospital in a body bag, I would say the ETCO2 pays for itself.

Since good providers are few and hard to find, I would say put the machine everywhere.

I agree with that. It's a great monitor. The worst case scenario with it is it is reading apnea incorrectly and the nurse is trying to improve ventilation. Not a bad situation.

However, JCAHO is definitely not mandating use of ETCO2 at this point.

 

[periopdoc]

Nope, worst case scenario is anyone interpreting minuscule blips of CO2 as adequate ventilation because "hey, there is CO2 present."

- pod

 

[Arch Guillotti]

Nope, worst case scenario is anyone interpreting minuscule blips of CO2 as adequate ventilation because "hey, there is CO2 present."

- pod

Nope its having no ETCO2 and attributing it to equipment problem.