Minimally invasive techniques make it possible for patients to receive complex procedures without going to the OR. Patients who receive procedural sedation outside of the OR tend to be older — by more than three years — than those sedated in the OR.1 Age, metabolism, personal history, and even genetics may all play a role in a patient’s response to sedation.2 And the recovery period following an outpatient procedure can be challenging for some patients, particularly if the patient is opioid naive.
Presented by an experienced clinician and employee of Medtronic, the following is a real patient story. It exemplifies the importance of continuous capnography monitoring before, during, and after an outpatient procedure requiring sedation.
View an infographic on respiratory compromise on the MedSurg floor.
Written by Gina Farquharson, MBA, MS, RRT-NPS, CPPS, Senior Technical Consultant, Global Field Market Development, Medtronic
Challenges of the opioid naive patient
My 78-year-old aunt was admitted for day surgery to repair a diaphragmatic hernia. She had never experienced narcotic sedation, and before surgery she wasn’t taking any pain medication — she was opioid naive.
Following the three-hour procedure and two hours in the recovery room, my aunt was discharged to the medical-surgical floor for further observation. She was given a dose of Dilaudid and prescribed two liters of oxygen.
As her niece, I was sitting with her in the room to keep her company, but as a trained clinician, I was keeping a careful eye on her during her recovery. She was wearing a pulse oximetry sensor, had on a blood pressure cuff, and appeared to be doing well. After she settled in, I noticed she was having episodes of central and obstructive apnea. I watched her for a while — her oxygen saturation would drop depending on the length of the apneas. Then she started to experience periods of hyperventilation, followed by apneas.
Her SpO2 measurement was hovering around 92. She wasn’t dropping below 90, but I kept waking her to take a breath; I wouldn’t let her go too long with these apneas.I asked the nurse if they would put my aunt on a capnography monitor to track her ventilation.
The nurse informed me that typically, the hospital only uses capnography monitoring for someone on a patient-controlled analgesia (PCA) pump. I explained that I witnessed my aunt experience multiple apnea episodes, that she had been given narcotics, and that she was an opioid naive patient.
As my aunt’s healthcare advocate, I escalated my request for a capnography monitor to a supervisor. In the meantime, clinicians administered my aunt two doses of Narcan to reverse the effects of the Dilaudid.
The respiratory department brought in the monitor. And once the device showed that her SpO2 and etCO2 measurements were consistently stable, we took her home.
Related: Download a list of key society guidelines on capnography during procedural sedation.
Standardizing capnography protocols
Not all patients have an advocate or family member in the room with them. In my opinion, all patients undergoing procedural sedation should be placed not only on pulse oximetry but also on capnography monitoring before, during, and after the procedure. Pre-procedure ventilation monitoring is important to establish a baseline. During the procedure, capnography monitoring offers early alerts to subtle changes in ventilation. And after the procedure it can help ensure returning the patient’s respiratory status to their normal state.
1. Nagrebetsky A, Gabriel RA, Dutton RP, Urman RD. Growth of nonoperating room anesthesia care in the United States: a contemporary trends analysis. Anest Analg. 2017;124(4):1261–1267.
2. Borrat X, Trocóniz IF, Valencia JF, et al. Modeling the influence of the A118G polymorphism in the OPRM1 gene and of noxious stimulation on the synergistic relation between propofol and remifentanil: sedation and analgesia in endoscopic procedures. Anesthesiology. 2013 Jun;118(6):1395–407.
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