10/1/2013

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Capnography: Standard of Practice for Medical & Surgical Patients Receiving 

Opioids

Robert L. Massey, PhD, RN, NEA‐BCDirector Clinical Nursing & Assistant Professor

ASPMN 23rd National Conference

October 9 – 12, 2013

• Authors Conflicts of Interest;

– R. L. Massey, PhD, RN, NEA‐BC   

– No Conflict of Interest

Conflict of Interest Disclosure

• Describe the role of Capnography monitoring in patient safety.

• Describe rationale for making Capnography a Standard of Nursing Practice

Objectives

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To assure safe, effective, patient‐centered, timely, efficient, and equitable pain management for all patients receiving opioid analgesia for. 

(IOM, 2001)

Vision

• Estimated 75% of cancer patients experience one of the following during the cancer continuum:

– Acute Pain– Chronic/ Neuropathic Pain– Cancer Pain

• Causes of Cancer Patient Pain– Surgical Trauma ‐ Generally Acute – Can become Chronic– Radiation‐Induced Damage– Neurotoxicity from Chemotherapy– Myofascial Pain Syndrome – trigger points that refer pain to other 

parts of body– Fistula Formation– Chronic Inflammation– Osteoradionecrosis – radiation damage to bone– Persistent Nerve Damage – least frequent due to invasion of tumor

(Polomano & Farrar, 2006)

Cancer Pain

Medical‐Surgical Co‐Morbidities

– Diabetes– Impaired Renal, Pulmonary, Hepatic & Cardiac functioning

– Obesity– Advanced Age– Sleep Apnea– Hx Smoking  

(Smith, 2007)

Cancer Pain ManagementMedical Surgical Risk Factors

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Treatment Related Factors

• Opioids

• Opioid Naïve or Tolerant???

• Concurrent use of:– Anxiolytics– Antihistamines– Antiemetic's– Muscle relaxants– Benzodiazepines – Anti‐Psychotic Agents

Administer Large Numbers of Opioids by Different Routes

8,258 8,351 8,3278,684 8,786

9,321

11,21911,604

12,400 12,451 12,620

11,81911,419

10,597 10,657 10,384

11,16311,726

15,45515,880 15,942

16,413 16,283

16,996

14,885 15,029

16,018

14,997

15,75116,064

14,480 14,67914,152 14,100 14,097

12,488

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Axis Title

Opioid Doses IV & PON = 189,786 & 273,709

IV

PO

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4

595

421

493 487

461

562

477465 471

501

394 391

469

538

348

430 431

462

314296

275 271

343356

273 275

349

274263

340 338

218

273 270

301

405

45

14 14 18 11 4 4 11 1932 34 41 37

59

15 13 14 60

100

200

300

400

500

600

700

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Axis Title

PCEA Transdermal & PCA Opioids 2011‐2013

Epidural

Transdermal

PCA

Introduction• 350,000‐750,000 In‐Hospital Cardiopulmonary (IHCA) Arrests 

Annually• 80%  do not survive• 50%  received Opioids• Opioid‐Induced Respiratory Depression (OIRD)

– Insidious Progression & Hard to Diagnose

• Outcomes worse if IHCA occurs – at night– weekends/holidays– during low staffing levels and/or – pt. nurse interactions at lowest

• No Improvement in Outcomes in 40yrs(Chan et al., 2008; Fecho et al., 2009; Lynn & Curry, 2011; Overdyk & Guerra, 2011)

• Low correlation with chronic/advanced disease and advanced age 

• Avg. Age = 57 years

• Median Hospital Stay = 3 days

• Review N = 139 in hospital deaths 62%avoidable

• Clinical signs of deterioration missed 48%

• Med‐Surg. Pts.

– Five times more likely occur

– Account for two thirds all in‐hospital deaths

(Johnson et al., 2011; Overdyk & Guerra, 2011; Sandroni et al.,2007)

IHCA Victim Factors

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• 47% Wrong dose medication errors

• 29% Improper monitoring

• 11% Other factors

– Excessive dosing

– Medication interactions

– Adverse drug reactions

(The Joint Commission, 2012)

Opioid‐Related Drug Events 2004‐2011

• Type I, II, & III 

• Type I – Compromised hypoventilation

• Type II ‐ Classic CO2 narcosis

• Type III – Occurs with sleep

– Ventilation & SPO2 cycling

– Instability of ventilation/upper airway control

– Fatal oxygen desaturation

– Enhanced by opioids or sedation(Lynn & Curry, 2011)

In‐Hospital Deaths: Three Distinct Patterns

“No patient has ever succumbed to respiratory depression while 

awake”

(American Pain Society, p. 23, 1992)

THOUGHT

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(Hagle, M.E., Lehr, V.T., Brubakken, K. & Shippee, 2004; Zimmerman, P.G. 2010)

ANALGESIA

SEDATIONRESPIRATORY DEPRESSION

Analgesia, Sedation, Respiratory Depression Cycle

• Majority IHCA – respiratory‐induced

– Not arrhythmias or hemodynamic

– 50% received opioids

• Hemodynamic monitoring ‐ not effective

– HR, B/P, RR, heart rhythm

• OIRD earliest warning signs

– Tachypnea, bradypnea, hypoxia, hypercarbia, mental status changes

• Respiratory Function & Level of Consciousness crucial

Why Respiratory Monitoring?

• Respiration two‐phase process:

• Phase I – Oxygenation

– O2 into lungs

– O2 aveoli to capillary blood for cellular metabolism

– CO2 produced

• Phase II – Ventilation

– CO2 diffuses into aveoli – from aveoli (exhaled)

– Abnormal CO2 levels (high or low) – adverse effects

(Clifford et al., 2012; Johnson et al., 2011)

Beware Respiratory Rates & Oxygen Saturation (SPO2)

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• SpO2 only measures ability of lungs to oxygenate blood

• Does not display info about RR, Depth, Apnea or CO2

levels

• Range = 90% ‐ 95%

• Supplemental O2 masks desaturation

• SpO2 late sign respiratory compromise in hypoventilating patients

• Meta‐Analysis 22,992 pts. – no benefit

(Eisenbacher & Heard, 2005; Fu et al., 2004; Hutchison & Rodriguez, 2008; Johnson et al., 2011; Lynn & Curry, 2011; Pedersen et al., 2009)

Why SpO2 Not Effective

RR & SpO2 False Negatives

• Produces waveform for each respiration:

– Respiratory rate and depth

– Presence of apnea

– Efficiency of ventilation

• Detects early signs of hypoventilation SpO2

does not

(Eisenbacher & Heard, 2005; Hutchison & Rodriguez, 2008; Johnson et al., 2011; The Joint Commission, 2012)

Why EtCO2 Effective

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• Affects 0.5% to 2.0% Post‐Op Pts.– EtCO2 studies indicate higher estimated rates

• Meta‐Analysis (Waugh et al., 2011)– N = 332– Addition of capnography– 17.6 time more likely to detect ORID vs. standard methods

• (95% CI, 2.5‐122.1; P < 0.004)• Concluded: End‐Tidal carbon dioxide monitoring 

impt. addition during Procedural Sedation and Analgesia (PSA) 

(Hutchison & Rodriguez, 2008; McCarter et al., 2008; Overdyk, Carter & Maddox, 2007; Waugh et al., 2011)

Opioid‐Induced Respiratory Depression

• 12,000 Root Cause Analyses since 1999

• 978 over 11 yrs. Involve Medical Devices

• 129 involved two devices

– 60 general purpose devices

– 69 Patient Controlled Analgesia Devices

• End Tidal CO2 could have prevented 60% of the incidents

• Recommended PCA pumps with integrated End Tidal CO2

VA Experience

Who is recommending the changes?– Nursing Pain PACT

– Pain Center

– Acute Pain Service

Why Change?– Ensure opioid therapy is provided safely

– Evidence supports need to monitor more frequently for 1st 24 hours after initiation

– Evidence supports close monitoring by nurses enhances effectiveness of analgesia and safety

– Reduce source of potential errors and over sedation

– “Do what’s best for the patient”

Reason for The Change

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Alaris® CareFusion with Guardrails®

• Implemented 2006• Alaris® EtCO2 modules• Order sets had check box for EtCO2 monitoring

– Inconsistent use

• Root Cause Analysis due to sentinel events contributed to making Standard of Nursing Practice

• January 2012 implemented as Standard of Nursing Practice

– Capnography Monitoring Policy

– Changed order sets

– Re‐educated all staff

– Team Huddles 

• Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration by American Society of Anesthesiologists Task Force on Neuraxial Opioids.

• Evidence in literature reviewed by task force supports recommendations to include increased PCA monitoring.

• The purpose of these Guidelines is to improve patient safety and enhance the quality of care by reducing the incidence and severity of opioid related respiratory depression, hypoxemia and/or hypercapnia.

(Anesthesiology, 2009,110:218–30)

PCA/PCEA Practice Guidelines

• Patients receiving PCA or IV opioid analgesia will be monitored every 1 hour for the first 12 hours and every 2 hours for the second 12 hours during the first 24 hours after initiation and/or escalation of opioid therapy.

– Respiratory Rate, Sedation Level, Depth of Respiration, and SpO2/EtCO2

• Patients receiving PCEA opioid analgesia will have End Tidal CO2 capnography monitoring for 1st 24 hours after initiation of therapy along with SpO2 monitoring.

– Exceptions: DNR & Supportive Care

Capnography Monitoring

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2012 N = 35

Avg. Age = 57.9

Age Range = 25 ‐ 80

Male = 17 (49%)

Female = 18 (51%)

2013 N= 62

Avg. Age = 53.6

Age Range = 14 – 88 yrs. 

Male = 20 (32%)

Female = 42 (68%)

PCA 15

Epidural 2

PO 7

IVP 14

Opioid Cont. Infusion 0

Transdermal Fentanyl Patch 2

Transmucosal Lozenge 0

PCA 32

Epidural 6

PO 12

IVP 21

Opioid Cont. Infusion 1

Transdermal Fentanyl Patch 2

Transmucosal Lozenge 1

Opioid Routes

15,964

15,708 15,636

15,672

16,998

16,113

16,404

15,866

17,244

16,845

16,966 17,015

16,301

16,818

16,741 16,770

17,588

16,432

17,541

17,426

17,56017,724

18,093

18,669

14,000

14,500

15,000

15,500

16,000

16,500

17,000

17,500

18,000

18,500

19,000

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Pt. Days

Pt. Days of Care/Month 2011 ‐ 2013

Pt.Days/Mo.

Mean = 16,837

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0.060.06

0.19

0.130.12

0.180.17

0.23

0.34

0.11

0.17

0.27

0.43

0.36

0.06

0.30

0.01

0.24

0.46

0.52

0.23

0.45

0.33

0.16

0.00

0.10

0.20

0.30

0.40

0.50

0.60

Sep Oct Nov Dec 2012 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2013 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

PSN Pain Reports./1000 Pt. Days 2011‐2012

Rates/1000 PD Mean = 0.23

0 0 0 0 0 0 0 0

1 1

3

2 2

3 3

4

6

2

3

5

7

6

1

5

1

4

8

9

4

8

6

3

4

‐2

0

2

4

6

8

10

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

Axis Title

PSN Pain Reports./Mo. 2011‐2013

# Reports

Mean

Linear (# Reports)

UCHPSN SystemImplemented

CapnographyStd. Nsg. 

1.01.0

3.0

2.0 2.0

3.03.0

4.0

6.0

2.0

3.0

5.0

7.0

6.0

1.0

5.0

1.0

4.0

8.0

9.0

4.0

8.0

6.0

3.0

4.0

0

2

4

6

8

10

12

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

2012

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

2013

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

Individual Values (X)

X‐Chart PSN Reports. 2011‐2013

PSNPain Mgnt.

Mean = 4.04

UNPL = 10.03

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1.0

0.0

2.0

1.0

0.0

1.0

0.0

1.0

2.0

4.0

1.0

2.02.0

1.0

5.0

4.0 4.0

3.0

4.0

1.0

5.0

4.0

2.0

3.0

1.0

0

1

2

3

4

5

6

7

8

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

2012

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

2013

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

Moving Ran

ge

m‐Range Chart PSN Pain 2011‐2013

mRange

Mean mRange =2.25

URL = 7.36

10

90

134

49

72

91

3951

126

210

5254

56

34

68

73 5256

7

75

127

41

65

81

35

45

116

198

4854

49

32

62

73

48

51

315

7 8 7 104 6

10 124

07

26

04 5

0

50

100

150

200

250

Sep Oct Nov Dec 2012 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2013 Jan Feb

Naloxone Pyxis Activity 2011 ‐ 2013

Removed from Pyxis

Total Admin.

Returned Unused

0.06

0.06

0.19

0.13 0.12

0.18

0.17

0.23

0.34

0.11

0.17

0.27

0.43

0.36

0.06

0.30

0.01

0.24

0.46

0.52

0.23

0.45

0.33

0.16

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

2011

Sep

Oct

Nov

Dec

2012

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

2013

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

Rates/Mo.

X‐Chart Pain Mgmt. Reports Rates/1000 PD

Rates/1000 PD

Mean = 0.23

UNPL = 0.60

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0

0.13

0.06

0.01

0.06

0.01

0.06

0.14

0.23

0.06

0.1

0.16

0.07

0.3

0.24

0.29

0.230.22

0.06

0.29

0.22

0.12

0.17

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

2011

Sep

Oct

Nov

Dec

2012

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

2013

Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

mRan

ge

mRange Pain Report Rates/1000 PD

mRange

Mean m‐Range =

URL = 0.46

• Increased number of PSN reports > 50%

• Narrowed Occurrence – Discovery Times

• Decrease in Naloxone usage

• Medical patients receiving multiple non‐opioid interacting medications

• Consistency in practice 1st 24 hours

Summary

• Technology alone in not the answer

• Must consider patients co‐morbidities

• Pain assessments have to be comprehensive – not just a number

• Capnography – not just a number either

– Still have to consider RR, Depth of Respiration, Sedation Level, Waveform

Nursing Implications

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QUESTIONS