What Is the Desired Spo2 Reading for the Patient With Pca

The Anesthesia Patient Prophylactic Foundation has noted an underappreciated risk of serious injury from patient-controlled analgesia (PCA)—including life threatening respiratory low (RD) in young, healthy patients—and has urged consideration of "smart" PCA pumps and continuous oxygenation and ventilation monitoring of patients receiving PCA therapy. St. Joseph'south/Candler Health System was the first U.Due south. hospital system to implement such technology. Clinical feel shows that non-invasive capnographic monitoring provides the earliest alert of RD. Use of this technology documented an incidence of PCA-related RD-bradypnea many times higher than previously reported. We describe implementation of "smart" PCA pumps with continuous respiratory monitoring and results achieved in meaning programming errors averted and patients protected even when the PCA infusion was correctly programmed. Our experience shows that continuous respiratory monitoring of PCA therapy, specially non-invasive capnography, assists clinicians in early identification of RD and other complications to prevent serious adverse events and the need for costly interventions.

Introduction

Effective pain direction is essential to patient satisfaction, quality of care, and institutional compliance with Articulation Commission standards.¹ Patient-controlled analgesia (PCA) is a widely used, effective method of opioid administration for postoperative pain management. However, PCA therapy is also associated with serious risks.² ^, ³ ^, ⁴ ^, ⁵ ^, ⁶ ^, ⁷

The Anesthesia Patient Safe Foundation notes that the significant, underappreciated risk of serious injury from PCA in the postoperative catamenia includes a low, unpredictable incidence of life threatening, opioid-induced respiratory depression (RD) in young, good for you patients.⁸ A recent written report using continuous noninvasive monitoring of both oxygenation and ventilation found that the incidence of RD based on bradypnea was many orders of magnitude greater than the 1 to 2 pct widely reported in the literature.^ix MEDMARX^SM and U.S. Pharmacopeia (USP) information show that when PCA pumps are involved, the chance for patient harm increases more than iii.five times.¹⁰

The Joint Committee has noted that health care professionals' concern about opioid-related RD is i of the barriers to adequate pain management.¹ Improving the safety of PCA is thus a major factor in improving both medication rubber and the quality of postoperative care.

Numerous factors can lead to opioid-related RD: prescribing errors, PCA pump programming errors, "PCA by proxy," improper patient selection, improper patient and clinician education,³ ^, ^four and the variability of patient response to opioid administration. Accurate dosing and administration of opioids are disquisitional. However, even when correctly programmed, therapeutic doses of opioids can suppress respiration.⁵ ^, ⁶ ^, ¹¹ Comorbidities, diagnosed or undiagnosed, also affect how a patient responds to a detail dose of narcotic,² ^, ^three ^, ⁴ even 1 that is within approved assistants limits. If a patient requires mechanical ventilation or another supportive intervention secondary to RD, this can issue in increased length of stay, risk of infirmary-acquired infections, and associated costs.

If detected early, most cases of opioid-related RD tin can be treated with naloxone. Withal, severe cases can exist fatal.¹¹ PCA opioid-induced episodes of bradypnea and desaturation tin can escalate to RD requiring rescue, and in-infirmary cardiopulmonary resuscitation is successful in fewer than one in five patients.⁹ ^, ¹² ^, ¹³ Detection of a patient's declining respiratory condition earlier progression to RD can help avert unwarranted outcomes and the possible need for critical care. Thus, safe, constructive apply of PCA requires monitoring of both do (i.eastward., correct pump programming) and patients (i.e., individual respiratory response to opioids).^two

Current protocols for respiratory monitoring of infirmary ward patients receiving PCA therapy typically require documentation of the respiratory rate (RR) and less commonly, the oxygen saturation (SpO₂) value, initially at 30-minute intervals but thereafter at intervals as far as 2 to iv hours apart.^ix RR is ofttimes determined by clinician assessment, even though manual respiration counts may exist inaccurate when compared to capnometry.¹⁴ SpO₂ is measured by intermittent or continuous pulse oximetry. Typically, only some high-gamble patients are monitored by capnography, a technology that assesses ventilation by measuring RR and the concentration of exhaled carbon dioxide (EtCO_two).

The American Order of Anesthesiologists emphasizes that, because ventilation and oxygenation are separate physiologic processes, monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory office by capnography.¹⁵ Oxygen saturation normally is maintained, even at a depression respiratory rate, so that pulse oximetry might neglect to detect respiratory deterioration, specially if a patient is receiving supplemental oxygen.⁷ The use of supplemental oxygen does not correct desaturation due to hypoventilation; it only delays the progression of respiratory failure from bradypnea to apnea. Thus, even continuous monitoring of heart charge per unit and SpO₂ by pulse oximetry is not a substitute for monitoring EtCO_ii, respiratory charge per unit, and apneic events past capnography. Capnographic monitoring can anticipate a patient's desaturation by warning of a decrease in RR and rise in EtCO₂.8 In a procedural sedation study, pulse oximetry identified only 33 percentage of those patients with respiratory distress, while capnography captured 100 percent.¹⁶

Until recently, continuous capnographic monitoring required that a patient be intubated, and its use was limited more often than not to patients in disquisitional care areas. Now noninvasive capnography systems with modified cannulae tin can be used for continuous monitoring of nonintubated patients in general care nursing areas. By providing clinicians with information on the patient'southward ventilatory response to PCA therapy, continuous capnographic monitoring helps provide an early on alarm of potential RD.²

The Anesthesia Patient Safety Foundation urges health care professionals to consider the potential safety value of continuous oxygenation and ventilation monitoring in patients receiving PCA therapy and implementation of "smart" (computerized) PCA pumps containing dose-error reduction software.^eight The Plant for Safe Medication Practices (ISMP) recommends that technology for PCA be adult that can alert clinicians to unsafe dose settings, programming errors, and RD.³ St. Joseph's/Candler Health System (SJCHS), a 644-bed, tertiary intendance, "magnet" system, is the first hospital system in the United States to implement such technology.^a The utilise of "smart" PCA pumps with continuous pulse oximetric and noninvasive capnographic monitoring was made the standard of care at SJCHS in 2004.

In this article, we describe the implementation and use of these technologies, including an automatic PCA "pause" feature, evolution of a patient selection algorithm, the innovative involvement of respiratory therapists in a multidisciplinary team approach, results achieved in averting significant programming errors that would have likely caused serious negative outcomes, patients protected from agin physiologic responses to PCA even when infusions were correctly programmed, and improved nursing satisfaction and confidence in their power to aggressively manage patients' hurting. In sharing our feel, results, and lessons learned, nosotros hope this information will be helpful to other health care professionals in their appreciation for the value of implementing PCA monitoring rubber systems as they work to improve hurting management, medication safety, and quality of intendance for all patients.

Implementation Methodology

St. Joseph's/Candler Wellness Organisation

St. Joseph'south Hospital and Candler Hospital, the two main facilities of SJCHS, are two of the oldest continuously operating hospitals in the Usa. Patient volume is 291,504 discharges annually. Staff includes 517 community-based, private practice physicians, 987 nurses, and 38 pharmacists. SJCHS is an American Lodge of Health-Organization Pharmacists-accredited residency site and trains 4 clinical pharmacy practise residents per yr.

In 2002, post-obit an extensive review and systematic evaluation of its nursing do past the American Nurses Credentialing Center, SJCHS received the designation of "magnet infirmary." Interaction amongst staff and administration is characterized by a high degree of collaboration. Our multidisciplinary Medication Fault Team includes pharmacists, respiratory therapists, adventure managers, physicians, and others. Experience has taught us that to meliorate patient rubber, the goal must be to better processes and focus on the problems, not on the individual.

IV Rubber Systems

In 2000, an ISMP article detailing the hazards associated with PCA¹⁷ prompted our Medication Mistake Squad to focus kickoff on infusion-related errors. In 2001, completion of an ISMP Medication Condom Self-Assessment^xviii led to an intense focus on the administration of intravenous (Four) medications. After evaluating various medication safety technologies, the squad determined that implementation of a modular, computerized Iv infusion safety arrangement with dose mistake reduction software would provide the greatest "speed to bear on" in terms of price, resource, time, and reduction of harm.¹⁹ In 2002, Four safety systems for large book infusions were implemented hospitalwide.

Prior to installation of the new systems, safety software embedded in the betoken-of-intendance units (the system's "brains") was used to create hospital-specific drug libraries with standardized concentrations, maximum and minimum dosing limits, and other infusion parameters for various patient intendance areas. If nurse programming of the infusion device exceeds the pre-established limits, the system generates an alert that must be addressed before infusion tin begin. Software logs tape all device programming, alerts, and whether the infusion was reprogrammed or cancelled in response to the alert (i.e., "near misses"). Continuous quality improvement information documented that the IV prophylactic systems helped avert meaning 4 medication errors with the potential for severe patient damage.^nineteen Wireless technology was deployed to support ongoing data collection for quality cess and to facilitate software upgrades.

PCA Exercise and Patient Monitoring

Recognizing opioids' potential for harm, the Medication Mistake Team sought additional technology that would not only help protect confronting PCA programming errors just also help protect the patient in one case infusion had begun. Respiratory therapy became an important member of the multidisciplinary squad.

"Smart" PCA pump, pulse oximetry, and noninvasive capnography modules were added to the organisation in 2004. A single safety technology platform with a common user interface for all modules increased ease of apply and reduced the time required for staff training. If either pre-established drug or respiratory limits are exceeded (pulse charge per unit <50 beats/min or >120 beats/min; SpO₂ <90 percent; RR <10 breaths per minute; EtCO_two >60 mmHg; apnea >30 seconds), the system generates alerts. If any of the pre-established parameters noted higher up are exceeded, a PCA "intermission" protocol can automatically halt drug infusion.

The organisation is designed to supplement, non substitute for, clinician monitoring. Figure 1 illustrates the multipurpose cannula used to collect exhaled CO₂ and to administrate O₂ to patients who may require supplemental oxygen. As shown in Effigy 2, past providing up to 24 hours of PCA dosing history with respective fourth dimension-based values from pulse oximetry and/or capnography, the system helps clinicians monitor patient response to self-administered opioids. Trend data allow clinicians to better assess a patient's physiologic response and assistance provide an early alarm of potential RD.

Figure 1

CO₂ sampling/O_ii delivery for nonintubated patients; modified cannula. Source: Oridion Capnography, Inc., Needham, MA. Used with permission.

Effigy 2

PCA, SpO and EtCO_two trending data: Representative examples. Source: Fundamental Health, Dublin OH. Used with permission.

An initial beta test catamenia was begun in June 2004. Subsequently 6 months of testing, continuous respiratory monitoring of each PCA patient became the standard of intendance. Pharmacy and nursing originally planned to buy a pulse oximetry module for each PCA module and a lesser number of capnography modules for use with loftier-risk patients. However, beta testing revealed the difficulty of predicting patient response to opioids and showed that capnography, not pulse oximetry, provided the get-go indication of opioid-related RD. As a issue, the original decision was reversed; implementation included a capnography module for each PCA module and a smaller number of pulse oximetry modules for use with selected patients receiving PCA analgesics.

Patient Choice

As shown in Figure 3, all SJCHS patients who receive PCA therapy take continuous capnographic monitoring and intermittent pulse oximetry monitoring. Continuous capnographic monitoring is used for all patients, while continuous pulse oximetry is used for selected individuals. Patients at loftier risk for deep vein thrombosis are also at risk for pulmonary embolism. In these cases, continuous pulse oximetry provides a more than sensitive assessment of inherent pulmonary pathology, while capnography helps protect against opioid-related RD. Patients with chronic obstructive pulmonary disease who are CO₂ retainers accept naturally high levels of EtCO₂ levels and besides crave continuous pulse oximetry monitoring. The SJCHS oxygenation protocol requires that oxygen saturation be maintained at greater than 92 percent; any patient whose SpO₂ is ≤92 percentage upon admission is monitored with both pulse oximetry and capnography. If a patient shows signs or symptoms of congestive heart failure, SpO₂ monitoring is required and a nurse is to contact respiratory therapy for assistance. In addition, nursing or respiratory therapy may initiate continuous pulse oximetry monitoring equally needed, someday they deem it necessary.

Effigy 3

Patient selection algorithm for SpO₂ and EtCO₂ monitoring. (DVT = deep vein thrombosis; COPD = chronic obstructive pulmonary affliction; OSA = obstructive sleep apnea; CHF = congestive heart failure).

Grooming

Nurses and respiratory therapists worked together to provide staff training on enhanced hurting management, pulse oximetry, and capnography monitoring. Topics included utilise of technology and appropriate clinical interventions based on patients' physiologic responses to PCA. In detail, training on capnography included patient assessment, evaluation of EtCO₂ wave forms and tendency data, recognition of patient-specific normal/abnormal values, appropriate interventions, and collaboration with physicians.

Clinical Practice

During continuous respiratory monitoring, a nurse responds to exceptional EtCO₂ or low RR alarms by stimulating the patient to take some deep breaths. In response to frequent alarms, the nurse arouses and stimulates the patient, verifies that the capnography module is functioning correctly, and if and then, contacts respiratory therapy. The respiratory therapist and nurse piece of work together to determine the all-time course of activity—eastward.g., ordering arterial blood gases to verify the patient's respiratory status or supporting the patient with supplemental oxygen or noninvasive ventilation (C-PAP or Bi-PAP). If they are unable to readily correct the situation and the patient further deteriorates towards respiratory failure, they consult the dr. regarding additional treatment and possible transfer to an intensive intendance unit. In addition, revised hospital PCA policy requires respiratory therapy to round on every PCA patient at least once every 12 hours.

Results

PCA Infusion Programming: Averted Errors

During the initial 4 months, 4 safety systems with PCA modules were used on one unit in each of the two SJCHS hospitals. During this fourth dimension more than 750 PCA syringes were initiated on the systems for a total of 225 PCA patients. Information drove documented 52 instances when a nurse received an alert that programming exceeded drug library limits and either reprogrammed or cancelled the infusion—i.due east., 52 averted errors.² Representative examples are shown in Tabular array i.

Tabular array 1

Examples of averted programming errors.

Patient Respiratory Monitoring: Averted Outcomes

During the first months of apply, continuous respiratory monitoring helped clinicians identify numerous cases requiring intervention by the respiratory therapist. These included cases in which PCA programming was correct, and opioid dosing was within established limits.

In the 33 months from July 2004 through March 2007, 16 patients with declining physiologic status were identified by continuous respiratory monitoring; unwarranted outcomes and possible transfer to the intensive care unit of measurement were avoided. This value is the number of instances for which there are documented case reports. There were other instances in which RR alarms were triggered, interventions made, and unwarranted outcomes averted. Yet, no case reports were submitted.

The following representative examples illustrate the effectiveness of continuous respiratory monitoring to assess patient response to PCA opioids and, in particular, the effectiveness of noninvasive, continuous capnography in detecting impending RD in nonintubated patients in noncritical care settings.^two

Postanesthesia Respiratory Turn down

An obese, 71-year-erstwhile male person with multiple comorbidities, including obstructive sleep apnea, had bilateral full knee joint arthroplasties. A PCA pump was set up in the postanesthesia care unit and programmed for patient "demand-but" dosing. A capnography module as well was fastened. The PCA demand button had not been pressed, and no PCA doses had been administered since pump setup.

Shortly after the patient was transferred to the medical/surgical unit, "EtCO_ii Loftier," "Low Respiratory Rate," and periodic "No Breath" alarms were activated, which prompted a STAT call from the nurse to respiratory therapy. Upon entering the room, the respiratory therapist noted that the patient had RD and marked sluggishness that required ambitious exact stimulation for arousal. The patient's EtCO₂ levels were in the mid-60s mmHg (nl 35 – 45), and RR was 4 to 6 breaths per infinitesimal (nl 10 – 14). His SpO_ii level on two.5 liters per infinitesimal (Lpm) of oxygen was 90 to 91 percent (nl >92 percent). The patient was assessed, stimulated, and positioned to optimize patency of his upper airway. A physician was called on consult and an arterial blood gas performed with the patient on oxygen at two.five Lpm. The results were pH vii.nineteen (nl 7.35 – 7.45); PCO₂ 61.2 mmHg (nl 35–45); PaO₂ 78 mmHg (nl 75 – 100); HCO₃ 23.5 mEq/liter (nl 22 – 26); and SaO₂ 91.three percent (nl >92 percent). The patient was placed on noninvasive ventilation (Bi-PAP) via full face mask.

Information technology was discovered that the patient had received additional narcotic analgesia in the postanesthesia recovery unit (not through PCA). The patient was given naloxone, immediately awakened, and his EtCO₂ level decreased from the 60s to the mid-40s. RR increased from 4 to vi bpm to 8 to 10 bpm. The SaO₂ increased from the low 90s to the upper 90s. The patient was awake, alert, and responding appropriately. Followup blood gases were pH 7.26; PCO_two 48.5; PO₂ 93; HCO₃ 22.1; and SaO₂ 95.viii.

As a result of clinical interventions prompted by continuous respiratory monitoring data, a possible adverse outcome was avoided. This case suggests that the postoperative period can exist one of the most critical times when respiratory monitoring is required, with or without PCA.

Obstructive Sleep Apnea Without Obesity

PCA therapy was initiated postoperatively for a normal-weight, 44-twelvemonth-onetime female with no known risk factors for PCA therapy.² Initial dosing was continuous PCA infusion of 1 mg/hr morphine and 1 mg every 6 minutes PCA doses, with a 4-hour maximum limit of 35 mg. When the patient arrived in the nursing unit, her oxygen saturations were in the high 80s. Afterward applying two liters of supplemental oxygen via nasal cannula, a nurse decreased the basal PCA infusion from 1 mg to 0.five mg. The patient's O₂ saturation increased to the high 90s.

Several hours afterwards commencement PCA the patient was put on continuous capnography. Initial EtCO₂ readings ranged from the loftier 50s to low 60s. Respiratory rate was 6 to 12 bpm, with periods of apnea when the patient fell asleep. While the patient was sleeping, the EtCO₂ module indicated frequent low respiratory charge per unit alarms. A nurse determined that respiratory rate by manual count was 4 constructive breaths/min. The nurse discontinued PCA therapy, began oral oxycodone hydrochloride 5 mg/acetaminophen 325 mg (Percocet^®) therapy, and connected the monitoring. The patient'southward respiratory status improved, as indicated by oxygen saturations in the depression to mid-90s, EtCO_two in the mid-40s, and a respiratory charge per unit of 12 to 14 breaths per minute. This case illustrates that a patient can be at risk for respiratory depression even with no known chance factors and when opioid administration is within established dosing limits. For this patient with no known risk factors for PCA therapy, continuous respiratory monitoring helped clinicians identify opioid-associated respiratory low and prevent a potential agin drug event.

Bilateral Pneumonia

Following orthopedic surgery, PCA therapy was initiated for a 56-year-old, 75-kg, Caucasian, female patient with a history of lung cancer and a lower lobe partial lobectomy.ⁱⁱ Patient monitoring included continuous pulse oximetry and capnography. Tendency information from the monitoring modules documented that her SpO₂ levels decreased from the mid-90s to the low 80s. EtCO_ii decreased from 36 to 32 mmHg; respiratory rate increased from 20 to 24 bpm. After respiratory therapy staff increased the patient's supplemental oxygen from 2 to ten liters, the patient's SpO₂ increased to the depression 90s. Two hours later the SpO_ii module generated alarms for SpO_two levels in the 70s, RR in the 30s, and an EtCO₂ of 31 mmHg. The patient was chop-chop transferred to intensive care. Pulmonary embolus was ruled out with advisable radiographic and laboratory tests. Breast 10-ray revealed bilateral pneumonia. In this instance, continuous respiratory monitoring, particularly pulse oximetry, alerted clinicians to the acute development of serious bilateral pneumonia.

Study Results: Greater Incidence of RD

Equally reported elsewhere,⁹ the pulse oximetry and continuous capnography monitoring modules were used in an observational written report of 178 patients receiving PCA therapy at SJCHS. Findings showed an incidence of RD based on desaturation consequent with previous estimates. However, we found the incidence of RD based on bradypnea was many orders of magnitude greater than the 1 to 2 pct widely reported in the literature.⁹ Defined by traditional "threshold criteria" (at least 1 2 minute or longer low-RR event), the incidence of RD was 58 percent. Defined conservatively (at to the lowest degree one ≥three-infinitesimal depression-RR event, RR <10 bpm), the incidence of RD was 41 percent.⁹

Nursing Satisfaction

Nursing staff indicate that the availability of dose error protection and continuous respiratory monitoring trend data allows nurses to feel more than comfortable in administering PCA therapy and in giving boosted medication so they can manage patients' hurting aggressively. Knowing that patients volition be more comfortable, nurses are more satisfied. Nurses are also alerted early to potentially life threatening events, such as RD during recovery, so they can intervene faster. A common user interface for PCA and monitoring modules increment ease of apply and reduce possibilities for fault.²

Discussion

More than three years' clinical experience with an Iv safety organization that combines PCA pump, pulse oximetry, and continuous, noninvasive capnography modules on a single platform has taught us the importance of the following issues regarding the management of postoperative hurting.

Multidisciplinary Team Arroyo

A highly collaborative approach is essential to effective pain management and to the selection, implementation, and utilize of this technology. Physicians, nurses, pharmacists, and respiratory therapists must work together as a team to maximize its benefits. Respiratory therapists play a vital role in nursing education, patient cess, and the development of a patient selection protocol and algorithm. During continuous respiratory monitoring, respiratory therapists may need to aid interpret the information. Noncritical care nurses and physicians initially may be unfamiliar with the information provided past these devices and accept problems applying the data to patient care. Unfamiliarity may make nurses reluctant to telephone call a doc when the system alarms. In these situations respiratory therapists provide valuable assistance.

Monitoring

Practice monitoring. Misprogramming 4 infusion pumps can result in serious, potentially life threatening adverse events.²⁰ Opioid analgesics are associated with a high run a risk of harm. Implementation of "smart" IV safety systems with dosing parameters for each narcotic is essential to assistance avert errors in PCA infusion programming.

Patient monitoring. Due to the variability of patient response to opioid analgesics, even when correctly programmed, therapeutic doses can result in an adverse drug event.² While some patient populations are at college risk of an opioid-related result, clinical experience has shown that it is not possible to prospectively identify all patients who may be at increased risk.^eight This fact underscores the need for continuous respiratory monitoring that provides trend data to the nurse at the bedside on a patient's physiologic response to PCA and helps prevent oversedation and undesirable outcomes. Utilise of this technology may also allow clinicians to identify undiagnosed clinical conditions that predispose patients to respiratory complications from IV opioids.

Capnography

SpO_two, EtCO₂, and RR are all of import clinical parameters that should exist used in conjunction with each other. SpO₂ reflects oxygenation, while EtCO_two and RR reverberate ventilation; one may be normal while the others demonstrate an abnormal respiratory status. Capnography provides the earliest indication of opioid-induced RD. It is important to monitor changes from a baseline EtCO₂ level. Equally the EtCO₂ level starts to increment, early on intervention and changes in medication can be made. Capnography monitoring should be used for all patients receiving PCA, not but for those at heightened take a chance of toxicity.

Demand for Greater Intendance

Clinical experience and report findings suggest that greater care might be needed with PCA therapy. The incidence of secondary RD may be greater than previously thought.⁹ Patients can progress to RD even when correctly programmed doses are inside the dose range of the rubber software information set.² In particular, the belief that most preventable episodes of RD are caused by programming errors²¹ might not be correct.

Improved Pain Management and Efficiency

Pain management. Continuous pulse oximetry and capnography monitoring during PCA therapy allows improved opioid delivery. By monitoring both pulse oximetry and capnography, medication doses can be adapted more safely to foreclose over- and undermedication and to go on patients comfortable. Patients whose pain is unrelieved from initial PCA therapy are at high risk for oversedation and respiratory depression from increased doses. The use of continuous pulse oximetry and capnography reduces this take chances.

Efficiency. In addition to providing early identification of impending RD in patients receiving PCA therapy, this technology besides allows respiratory therapists to intendance for patients more efficiently, so that existing staff can oversee more patients. Earlier identification of respiratory distress allows respiratory therapists to intervene before a patient's condition becomes serious, which saves time and helps increment the likelihood of a positive event.

Reduced Likelihood of Disquisitional Events

Every bit a result of training and working with respiratory therapists, nurses can increase their power to translate trend data from capnography and pulse oximetry. The availability of these information enhance clinician assessments and their power to intervene earlier, thereby reducing the likelihood of disquisitional events.

Boosted Applications

SJCHS clinicians have used the respiratory monitoring modules with non-PCA patients, such as those receiving epidural infusions, moderate sedation, or procedural sedation. Respiratory therapists have used the capnography modules to monitor patients in respiratory failure on hypoxic bulldoze, for whom increasing oxygen assistants by only 0.25 Lpm can accept agin furnishings. Compared with current monitoring by blood gas analysis, the use of capnography can allow clinicians to titrate supplemental oxygen assistants much more than efficiently. Capnography can likewise help early detection of severely asthmatic patients who are get-go to "fatigue out" and get into RD, so that aggressive treatment might prevent ventilation and intubation.

Conclusion

Data indicate that the utilize of "smart" PCA infusion devices with dose error-reduction systems helps avert significant patient damage from inadvertent misprogramming of PCA therapy by nurses. In improver, capnography and pulse oximetry are valuable tools that assist clinicians with early identification of PCA-related RD and other complications to preclude serious adverse events and the need for costly interventions. The availability of combined dosing and respiratory tendency data greatly enhances clinical assessments of patients receiving PCA therapy. Nurses are more satisfied using these technologies, patients' pain is better controlled, safety is improved, and plush adverse events are avoided.

Capnographic monitoring to measure ventilation (RR and EtCO₂) is peculiarly important because information technology can provide an before alert of respiratory depression compared to pulse oximetry (SpO_ii) in some patient populations. Thus, the combination of Iv safety system components allows monitoring of both practice (PCA programming) and patients (individual respiratory response to opioids). Implementation of "smart" PCA pumps combined with continuous respiratory monitoring is in keeping with professional practice recommendations and can help hospitals comply with Joint Commission standards for effective pain management, while improving medication safety and quality of care.

References

1.
2.: Maddox RR, Williams CK, Oglesby H, et al. Clinical experience with patient-controlled analgesia using continuous respiratory monitoring and a smart infusion system. Am J Health Syst Pharm. 2006;63:157–164. [PubMed: 16390930]
iii.: Part Ii: How to preclude errors. ISMP Medication Safety Alert; Jul 24, 2003. Safety bug with patient-controlled analgesia.
4.
5.: ISMP Medication Safety Alert; Jun 17, 1998. [Accessed April 13, 2008]. Frequent problems with medication systems noted during ISMP hospital evaluations. Part 2. Available at: www.ismp.org/Newsletters/acutecare/articles/19980617.asp.
half dozen.
7.: Overdyk FJ. PCA presents serious risks. [alphabetic character] APSF Newsletter. 2005;20:33.
8.: Weinger MB. Dangers of postoperative opioids. Anesthesia Patient Condom Foundation newsletter 2006–2007. [Accessed April 13, 2008]. pp. 21pp. 61–88. Available at: www.apsf.org/assets/Documents/winter2007.pdf.
9.: Overdyk F, Carter R, Maddox R, et al. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient controlled analgesia. Anesth Analg. 2007;105:412–418. [PubMed: 17646499]
x.
11.: Etches RC. Respiratory depression associated with patient-controlled analgesia: A review of viii cases. Can J Anaesth. 1994;41:125–132. [PubMed: 8131227]
12.: Schneider AP II, Nelson DJ, Brown DD. In-infirmary cardiopulmonary resuscitation: A xxx-yr review. J Am Board Fam Pract. 1993;half-dozen:91–101. [PubMed: 8452077]
thirteen.: Davis TA, Mathewson HS. Opioids and respiratory depression. Resp Care. 1999;44:78–80.
14.: Overdyk FJ. Respiratory depression in PCA patients: What continuous respiratory monitoring has revealed. Presented at the 6th annual briefing – Pain Direction and Patient-Controlled Analgesia: Improving Safety and Quality of Care; San Diego, CA. 2005 Nov.
15.: American Society of Anesthesiologists Task Forcefulness on Sedation and Analgesia past Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002. [Accessed April xiii, 2008]. pp. 1004–1017. Available at: world wide web.asahq.org/publicationsAndServices/sedation1017.pdf. [PubMed: 11964611]
sixteen.: Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxide monitoring during procedural sedation. Acad Emerg Med. 2002;9:275–280. [PubMed: 11927449]
17.
xviii.: Smetzer JL, Vaida AJ, Cohen MR, et al. Findings from the ISMP Medication Prophylactic Self-Assessment® for Hospitals. Jt Comm J Qual Condom. 2003;29:586–597. [PubMed: 14619351]
19.: Williams C, Maddox RR. Implementation of an 4 medication safety organization. Am J Wellness Syst Pharm. 2005;62:530–536. [PubMed: 15745919]
20.: Williams CK, Maddox RR, Heape E, et al. Application of the 4 Medication Damage Alphabetize to assess the nature of damage averted past "smart" infusion rubber systems. J Patient Saf. 2006;2:132–139.
21.: Carpenter RL. Optimizing postoperative pain management. Am Fam Physician. 1997;56:835–44. [PubMed: 9301576]

a: The Alaris^® System with the Guardrails^® Suite of condom software, Cardinal Wellness, Inc., San Diego, CA, with Nellcor OxiMax™ pulse oximetry technology and Oridion's Microstream^® capnography applied science.

boswellexhavy.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/books/NBK43753/