I have always advocated that EtCO2 for ED procedural sedation (deep sedation) is a patient safety issue. Then I came across a paper to challenge this belief…
End-Tidal Capnometry during Emergency Department Procedural Sedation and Analgesia
I was lucky enough to get lead author, Sam Campbell, on the podcast to discuss this paper.
Other Papers Published on the Topic
Prior Procedural Sedation Episodes
- EMCrit 4 – Procedural Sedation – Part I
- EMCrit 29 – Procedural Sedation, Part II
- EMCrit 151 – Procedural Sedation Part 3 with Jim Miner
Additional New Information
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- EMCrit Wee – Adaptive Support Ventilation (ASV) - June 24, 2024
- EMCrit RACC-Lit Review for June 2024 - June 18, 2024
- EMCrit Wee – Additional Thoughts on the PREOXI Trial - June 15, 2024
Though hypoxia is much more important than hypercapnia, clinicians who perform PSA should be focused primarily not on oxygenation, but on ventilation. Clinicians should be focused on ventilation not because ventilation clears carbon dioxide– we don’t really care about carbon dioxide–but because ventilation predicts oxygenation. Although oxygenation is the endpoint we care most about, to focus on oxygenation and ignore ventilation is to focus on the speedometer and ignore the fuel gauge. In addition to predicting oxygenation, ventilation also demonstrates airway patency. So when ventilation is good, you have assured A and B, which is 95% of what you care… Read more »
Hey Scott, Read the same paper and great podcast by the way…Here are several reasons why this paper doesn’t apply to all procedural sedation procedures in the ED 1. This was capnometry NOT capnography (i.e. no waveform) 2. Many of the procedures included where short, simple procedures where you wouldn’t expect capnometry to affect any patient-oriented outcome 3. Propofol was used for 95% of the sedations (i.e. quick on and off) which may not generalize to longer acting agents (i.e. ketamine) 4. Critical care paramedics who had no other distractions focused primarily on procedural sedation which is different than the environment most of us… Read more »
There was indeed capnography, what made you think it wasn’t? Many, probably most ED procedures are short, simple procedures Ketamine is a dissociative agent and is associated with the least incidence of resp depression–if there study had a bunch of ketamine, that would be a confounder. Proprofol is exactly what we want to test. If anyone is still using midaz/fent for deep sedation, you would def want etco2, but nobody should be doing that–it is horrible practice. Yes–that was the point I made repeatedly think that was already covered in point #2, no? this is by far the largest RCT… Read more »
Interesting that they titled their paper capnometry…but in doing a deeper dive, the monitor they were using did in fact have waveform (my mistake).
Hi Scott. This seems like a strange argument. Agree that ETCO2 wavefrom capnography is is cheap and easy as part of any sedation (cost of the plastic tubing). If you can find the kit that both delivers nasal O2 and samples then it is very convenient and cheap. My practice for PSA for brief painful procedures eg fracture reduction or abscess drainage (99% of my work) is to use ETCO2 and I tell the proceduralist to be poised, wait for that moment of apnoea as the sedation drug washes over the brain and that is the moment to do the… Read more »
love the idea of ETCO2 as a teaching tool! fantastic addition to the argument.
The EKG monitor has a respiratory rate function, that is sometimes turned off because patient positioning can make it more or less accurate. If you turn that function on pre sedation you’ll know it’s accurate (or not) for that patient, and you’ll get an apnea alarm.
I too have never seen the benefit of capnofraphy unless I’m a long term intubation or code.