A randomized controlled trial of capnography during sedation in a pediatric emergency setting

Abstract

Objective Data suggest that capnography is a more sensitive measure of ventilation than standard modalities and detects respiratory depression before hypoxemia occurs. We sought to determine if adding capnography to standard monitoring during sedation of children increased the frequency of interventions for hypoventilation, and whether these interventions would decrease the frequency of oxygen desaturations. Methods We enrolled 154 children receiving procedural sedation in a pediatric emergency department. All subjects received standard monitoring and capnography, but were randomized to whether staff could view the capnography monitor (intervention) or were blinded to it (controls). Primary outcome were the rate of interventions provided by staff for hypoventilation and the rate of oxygen desaturation <95%. Results Seventy-seven children were randomized to each group. Forty-five percent had at least one episode of hypoventilation. The rate of hypoventilation per minute was significantly higher among controls (7.1% vs. 1.0%, p=.008). There were significantly fewer interventions in the intervention group than in the control group (OR 0.25; 95% CI 0.13, 0.50). Interventions were more likely to occur contemporaneously with hypoventilation in the intervention group (2.26, 95% CI 1.34, 3.81). Interventions not in time with hypoventilation were associated with higher odds of oxygen desaturation <95% (OR 5.31; 95% CI 2.76, 10.22). Conclusion Hypoventilation is common during sedation of pediatric emergency department patients. This can be difficult to detect by current monitoring methods other than capnography. Providers with access to capnography provided fewer but more timely interventions for hypoventilation. This led to fewer episodes of hypoventilation and of oxygen desaturation.

A systematic review of capnography for sedation

“…We included six trials with 2524 participants (Fig. and Table ) having: colonoscopies ; emergency department procedures ; and gynaecological procedures . Three trials implemented protocols to titrate sedation to capnography measurements .…”

“…Three trials implemented protocols to titrate sedation to capnography measurements . Five trials used propofol to sedate adults and one study used midazolam or ketamine to sedate children : all participants were ASA physical status < 4. The risks of performance and assessment biases were substantial due to lack of blinding (Fig.…”

Moderate and deep sedation for non-invasive paediatric procedures in tertiary maternity and children’s hospitals in China: a questionnaire survey from China

“…This reveals that these monitoring procedures are adopted less frequently than previously reported [23]. End-tidal carbon dioxide monitoring is believed to be more sensitive than pulse oximetry for respiratory events, which can lead to hypoxemia during procedures [24,25]; the latest ASA guidelines also state that continuous monitoring of ventilatory function with capnography should supplement standard monitoring [9].…”

High‐flow oxygen in patients undergoing procedural sedation in the emergency department: A retrospective chart review

“…severe COPD) should be picked up in the presedation assessment, and the use of end-tidal carbon dioxide monitoring would ensure episodes of apnoea or hypoventilation are detected. [20][21][22] The use of NRB mask to deliver high-flow oxygen is simple, safe and inexpensive, and we would advocate that it be evaluated further.…”