Tuesday, March 30, 2010

Request for Proposal

The Post Anesthesia Care Unit at St. Jude Hospital in Fullerton, California is a 12 bay unit servicing on average forty surgeries per day. Standard monitoring includes three lead EKG, non-invasive blood pressure, pulse oximeter and respiratory rate. The PACU patient population range is from infancy to elderly and surgery focus on general surgery, orthopedics, gynecological, vascular and neurosurgery. The PACU is currently using Phillips brand Intellivue Monitoring system and has three CO2 monitoring extensions. St Jude is also using systems from Nellcor and Alaris which both have capnography capabilities.


Evidence base review of current medical research verifies that using pulse oximetry does not capture true measurement of ventilation. Pulse oximetry measures oxygenation not ventilation. Patients in the post operative period are at higher risk for hypoventilation and sedation from the combination of anesthesia and analgesic medications. Also the patient controlled analgesic (PCA) pumps are initiated in the PACU which can add to sedation and hypoventilation. The PACU nurse must make critical decision when medicating for pain and providing safety for the patient. Sometimes sedation comes before analgesia, the patient states high pain level but no relief, but they are progressively becoming more sedated. Using capnography can capture changes five minutes before the pulse oximeter shows decline (Cashman & Dolan, 2004). With the use of capnography the nurse will have the information needed to more accurately assess the patient and provide safe medication administration (Spikoff, 2006).

Task to be Accomplished

The clinical needs assessment of current equipment and practice reveals that the PACU needs a flexible capnography system that could monitor both intubated and non-intubated patients ranging in age from infancy to elderly. The PACU has only three modules in which to monitor capnography; education on using the module has been minimal and the end-tidal CO2 capability is not being utilized. The PACU nursing staff will require education on current standards and capnography monitoring. The capnography system must network with current computer charting system.

Potential Vendors

The PACU is currently using the Phillips Intellivue monitoring system. The Royal Phillips Electric Company of the Netherlands is a diversified health and well being company. The vision of Phillips is people focused, market driven company that is organized around its consumers and markets. In 2009 in adjustment to decrease sales of 19% Phillip started an aggressive $148 million reconstructing process (Electric). Phillips has a strong cash flow because of its reconstructing process. Phillips provides a mainstream CO2 extension for the multi-measurement server Intellivue. This extension can monitor both intubated and non-intubated patients and can be used wide age range from neonates to the elderly. Phillips provides online nursing education as well as a user guide book. The Phillip monitors in use are currently networked to computers and automatically downloads the vital signs to the patient computer chart.

St. Jude Medical Center is using Alaris infusion pump. Alaris is a division of Cardinal Health Care. Cardinal Health Care is an eighty-seven billion dollar global manufacturer and distributor of medical supplies and products. The vision of Cardinal Health Care is to be the premier global health care company who make health care safer and more productive. The Alaris division earned 2.7 million in revenue 2008, employs seven thousand people (Health C. ). The Alaris system is a state of the art infusion device which is has the Gaudrails safety software. Alaris is flexible wireless networking system which has extensions to monitor both pulse oximetry and Co2 levels. They combine these devices with the PCA pain pump to provide safety shut off if the patients CO2 level changes to unsafe level. The Alaris is flexible also in the fact that it can travel throughout the hospital stay since it is mounted on an infusion pole.

Nellcor is a division of Covidien which is a leading health care manufacturing company. Covidien earned 10 billion dollars of revenue in 2008 (Health C. ). The mission of Covidien can be summed up in four words: accountability, diversity, collaboration and compassion (Health C. ) Nellcor manufactures a handheld CO2 monitor NPB-70. The NPB-70 can be use for spot check monitoring or minimal monitoring; and can be used to monitor capnography for both intubated and non-intubated patients ranging in ages neonates to elderly. Nellcor has online education that provides nurse with continuing education credit. Nellcor also provides a loaner program when device is being serviced. The user manual is available on line as well as accessories to the device. The NPB-70 can be purchased with one, three and five year money back guarantee.


Cashman, J., & Dolan, S. (2004). Respiratory and hemodynamic effects of acute postoperative pain management: evidence from published data. British Journal of Anaesthesia , 212-223.

Electric, R. P. (n.d.). about us. Retrieved July 23, 2009, from Phillips sense and simplicity: http://www.philips.com/global/index.page

Health, C. (n.d.). about us. Retrieved July 22, 2009, from Cardinal Health: http://www.cardinal.com/us/en/aboutus/

Health, C. (n.d.). fact sheet. Retrieved July 22, 2009, from Covidien: http://www.covidien.com/covidien/pageBuilder.aspx?topicID=161272&page=AboutUs:CorporateFactSheet

Spikoff, M. (2006, July 24). Adding O2 and Co2 moitoring to PCA improves patient safety. Drug Source , p. 14.

Saturday, March 27, 2010

Posting Videos from You Tube

In order to embed a video from Youtube,
You need to copy the embedding code.
I took a screenshot for you so you know exactly where to find the embedding code.
click on the button that reads EMBED, copy the code (right click) - and then go to NEW POST on your blog and paste the code.
That should do the trick!
Let me know if you need further assistance!

Tuesday, March 23, 2010

Strategic Planning

Current Situation

Can End-tidal CO2 (ETCO2) monitoring be used as a tool for detecting hypoventilation and over-sedation in Post Anesthesia Care Unit (PACU)? An internal environment evaluation was obtained by using a three question evaluation tool. See following page to view questions figure 1. Four Staff members were interviewed: Manager of PACU, shift Coordinator, and two Anesthesiologist. Results as follows:

Name Question 1 Question 2 Question 3

Manager yes no no

Shift Coordinator yes no no

Anesthesiologist 1 no no yes

Anesthesiologist 2 no no no

It was discovered that the Anesthesiologist are unaware of any sentinel events which showed that the reporting system does not include the Anesthesia department. The Manager and Shift Coordinator were both aware of events that occurred because of over sedation/hypoventilation. All agree that using pulse oximeter only detects oxygen saturation and can not be used to evaluate ventilation. Only one person interviewed was aware of current trends in using ETCO2 in other settings outside intensive care units.


The goal or vision of using ETCO2 will be that patients are monitored for ventilation (not just oxygenation) and increase patient safety.


PACU uses the Phillips Intellivue Monitor which has the capability to monitor ETCO2 using side stream nasal filter line for non-intubated patients. The PACU stocks three modules and three different sizes of nasal filters. The Respiratory department has portable bedside capnography/pulse oximeter which can be used as a one time spot check or for continuous monitoring. Exploration of the use of ETCO2 monitoring would need to include stake holders from the general surgeon, anesthesiologist, manager, staff nurses, respiratory therapist, and education department. It is evident that the capability to use ETCO2 is available on a limited basis because of so few monitoring devices are available. Organizational needs are: identifying and reporting sentinel events, education and training on using ETCO2 monitor, deciding which group of clients would be best served monitoring ETCO2 (post operative patients using patient controlled analgesics), and evaluating and choosing device.


Lessons learned from the past included not identifying all the stake holders and making changes without a full educational plan. The phasing for this project will include: gathering data of sentinel events to help define the problem, meeting with stake holders to share evidence based research, choose best device, designing educational plan, implementing the use of ETCO2, and evaluating the effectiveness of ETCO2.

ETCO2 Internal Questionnaire (fig.1)

Question Yes No N/A

Are you aware of a sentinel event cause by over sedation/hypoventilation post-operatively?

Can pulse oxiemtry measure or detect over sedation/hypoventilation?

Can ETCO2 monitoring be used as a tool to detect or prevent over sedation/hypoventilation in post operative patient?

Sunday, March 21, 2010

Use of End-tidal Co2 Monitoring to Detect Hypoventilation and Sedation in Pain Management

Statement of Problem
Pain management of the post-operative patient is important because pain control improves a patient’s ability to ambulate, deep breath, and decreases length of stay in the hospital. Pain is the fifth vital sign and is assessed in Post Anesthesia Care Unit (PACU) every fifteen minutes. Opioid use preoperatively has brought with it new challenges in pain management. Because patients are more tolerant to opioids nurses are giving higher doses of opioids than ever before. The combination of increased amounts of opioids given and anesthesia has created a new problem. Patients receiving higher doses of opioids are at risk for over sedation.

Over sedation is defined as a change in mental status, decrease in respiratory rate (hypoventilation) below ten breaths per minute, and drop in pulse oximerty (PO %) below 92%. Hypoventilation is dangerous situation which can lead to apnea, increase Co2 blood levels, and chest wall rigidity. The standard of care in the PACU for hypoventilation and sedation is to perform wake up regime and apply supplemental oxygen.

Research has shown that applying supplemental oxygen may improve the PO% reading but does not improve ventilation. Patients may have normal PO% and yet have apenic episodes. End-tidal Co2 (ETCO2) monitoring may be the solution to this problem; as the pulse oxemitry measures oxygenation the ETCO2 measures ventilation. Could ETCO2 monitoring be a tool in guiding the PACU nurse as she medicates by detecting hypoventilation and sedation?

Review of Research Literature

Cashman and Dolin(2004) did a medline research of 800 articles which 167 articles where chosen to determine effects of pain medication, such as respiratory depression and hypotension, given to patients after surgery. They were able to use the research to define what respiratory depression from analgesic use is: respiratory rate less than ten breaths per minute, PO% less than 90%, and Co2 level of 50 mm Hg. Fitzpatrick (2000) for his thesis designed a research project which compared the typical Etco2 monitor with nasal prong ETCO2 monitor. The conclusion showed that readings between the two kinds of devices showed positive correlation. This research will open the door to the newer hand held device which is non-invasive and can be used on non-intubated patient.

Sipkodd (2006) and D’Archy (2009) discuss research that shows using ETCO2 monitoring in conjunction with pulse oximetry provide increase patient safety in detecting increase hypoventilation and sedation when medicating with opioids. Both Core Curriculum for PeriAnesthesia Nursing (2004) and Core Curriculum for Critical Care Nursing2006) address potentials problems of pain management and sedation.

Aim of Project

The aim of this project is to find an ETCO2 monitor that can be used at bedside or in conjunction with current hemodynamic monitoring system in the PACU setting to detect hypoventilation and sedation to increase patient safety in pain management.

Outline of the Project

First, clear and through definition of problem will need to be explored and current practices in PACU need review? Next, research of the different ETCO2 devices available and discover accuracy, affordability and ease of use for bedside care. Thirdly, design simple three week study of using ETCO2 monitor in conjunction with PO in detecting hypoventilation and sedation and possibly comparing two or three different ETCO2 devices. Project and conclusion will be presented to Nursing Practice Council and Nursing Informatics 103 class.


Alspach, J. (2006). Core Curriculum for Critical Care Nursing. St. Louis: Saunders.

Cashman, J., & Dolan, S. (2004). Respiratory and hemodynamic effects of acute postoperative pain management: evidence from published data. British Journal of Anaesthesia , 212-223.

D'Archy, Y. (March/April 2009). Tip your cap to capnography. Nursing made incrediably easy , 5-6.

Fitzpatrick, L. (2001). Correlation between end-tidal carbon dioxide measured by capnoxygen mask and nasal cannula. Uniformed Services University of the Health Sciences.

Fu, E., Downs, J., Miguel, R., Schweiger, J., & Smith, R. (2003). Supplemental oxygen impairs detection of hypoventilation by pluse oximetry. Chest , 1552-8.

Quinn, D., & L., S. (2004). Perianesthesia Nursing Core Curriculum. St. Louis: Saunders.

Spikoff, M. (2006, July 24). Adding O2 and Co2 moitoring to PCA improves patient safety. Drug Source , p. 14.

Tuesday, March 9, 2010