Monday, May 30, 2011

The New Standard

The Anesthesia Overlords have spoken. Starting July 1, end tidal CO2 monitoring will become mandatory in sedation cases. The addition of capnography in an anesthesiologist's arsenal for patient safety was detailed in the Standards For Basic Anesthetic Monitoring released by the ASA House of Delegates on October 20, 2010 and effective July 1, 2011. I printed an excerpt below relevant to our discussion. This is reprinted from section 3.2.4 of the Standards. Click on the picture below if the printing it too small to read.
Notice that it says, "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." It doesn't say "or". It says "and". So no longer is just observing for chest wall movement or listening for breath sounds adequate. If a caregiver giving sedation wants to stay within acceptable standards of practice, that person will also have to monitor ETCO2.

This is good news for all patients. Capnography has been essential in the ASA's drive to making anesthesia as safe as possible. This, along with the invention of the pulse oximetry, has drastically improved patient safety over the past twenty years. Why the ASA doesn't make ETCO2 monitoring mandatory immediately is puzzling to me. How can delaying this by nine months from its approval help patients?

This is also a shot across the bow for medical personnel who have been lulled into thinking anesthesia is so safe that anybody can give it with little consequence. I'm speaking to you gastroenterologists, who push versed, demerol, dilaudid, or your holy grail, propofol, into your patients for their endoscopies. I'm talking to you cardiologists who give sedation for your cardiac caths but don't realize the patient has become apneic until the O2 sat has dropped into the 70's. Or the interventional radiologists who think they can give some sedation without adequate monitoring of the patient's physiologic status. This new ASA standard makes no distinction between caregivers. Whether they are MD's, CRNA's, AA's, or RN's, ETCO2 monitoring must be performed if sedation is being given.

People think that moderate sedation is somehow less dangerous than general anesthesia. My contention is that it is just as, or even more dangerous, than general. The airway is not protected. It is often given by people who are not familiar with the full consequences of sedatives. And if an airway emergency occurs, people familiar with emergency intubation are not immediately available. So this new mandate from the ASA is long overdue. And all you doctors who don't follow the new guidelines, well I'm sure the malpractice lawyers will have a field day with you in the courtroom when, not if, an airway incident happens.

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