Title: Audit of use of end-tidal carbon dioxide monitoring for rapid sequence induction and patient transfer in non-theatre situation

Sangram Patil1
Madhu Gowda2
1. Specialist Registrar in Anaesthetics, Morriston Hospital Swansea, SA6
6PU, UK.
2. SHO in ITU, Morriston Hospital Swansea, SA6 6PU, UK.

Introduction:

End tidal carbon dioxide monitoring gives indication of successful expiration. Therefore it is recommended in anaesthetic and other airway management scenarios. Various specialist societies, including Royal College of Anaesthetists, AAGBI, and Intensive Care Society, have recommended use of end tidal carbon dioxide as a basic standard for rapid sequence induction and patient transfers in or out of hospital. There is evidence which suggest that monitoring end tidal carbon dioxide helps improving patient safety and quality of care.

Objective:

To know the practice with regards to end tidal carbon dioxide monitoring in our department and give recommendations for improvement in practice. For this to be audited to do a survey of use of etCO2 monitoring amongst trainees in our department.

Method:

A simple form was distributed amongst trainees and they were requested to questions and also given choice to express the factors related to etCO2 monitoring the end of the survey. The survey consisted of five simple questions. Out of 30 forms distributed- 21 forms were received back.

Results:
Did you use end tidal carbon dioxide monitor in A & E the last time you intubated patient?
Yes 8 No 12 Never attended intubation in A &


Did you use end tidal carbon dioxide monitor the last time you transferred the intubated patient inside the hospital?
Yes 9 No 12 Never attended intubation in A & E 0

Did you use end tidal carbon dioxide monitor the last time you transferred the intubated patient outside the hospital?
Yes 10 No 2 Never attended intubation in A & E 9

Are you aware of any national/local recommendations for etCO2 monitoring during patient transfer?
Yes 9 No 11


If you answered no to questions 1 2 3 Why didn't you use the etCO2 monitor in these situation?
a. etCO2 monitor not available at all - 3
b. etCO2 monitor was not provided even after your request- 7
c. you don’t think etCO2 monitor is required in above situations-1
d. you are not sure whether it is necessary to use etCO2 monitor in above situations- 4
e. Any other reasons- free comments-
capnograph was available only after repeated requests
Most of the A & E staff are unaware of where capnograph connectors are kept
There is usually delay in getting the capnograph in A & E
You never get it if you don’t ask for it.
Very useful audit!


Discussion:
Difficult or failed intubation is a serious problem. This can lead to potential oxygenation problems and is associated with significant mortality and morbidity.1
Difficult airway society (DAS) has recommended capnograph as a method to detect tracheal intubation as a monitoring for all routine intubations (2).
Rapid sequence induction (RSI) is increasingly used by emergency physicians in the emergency department. A feared complication of the technique is the inability to intubate and subsequently ventilate the patient (3). During RSI clinical assessment of proper placement of endotracheal tube, including direct visualization, auscultation, chest rise and tube condensation, cannot always confirm proper placement of the endotracheal tube. (4)
Unintentional hyperventilation occurs during the intrahospital transport (5). The standard of care and monitoring during transport should be at least as good as that at the referring hospital or base unit (6). The minimum standards required for all patients are:
_ Continuous presence of appropriately trained staff
_ ECG
_ Non-invasive blood pressure
_ Arterial oxygen saturation (SaO2)
_ End tidal carbon dioxide (EtCO2) in ventilated patients
_ Temperature (preferably core and peripheral).

These guidelines apply to the transport of critically ill adult patients in the UK outside of the normal critical care environment. They apply both to patients transferred between hospitals.
Royal college of anaesthetists of UK also has recommended the use of end tidal carbon dioxide for patient transfer (7). The association of Anaesthetists of great Briton and Ireland (AAGBI) has given guidelines for anaesthetizing patient (8), which obviously are also valid for rapid sequence induction (as this involves anaesthetizing the patient). The Association has recommended etCO2 monitoring as a basic requirement for anaesthetizing any patient.

Recommendations:
Awareness of what is end tidal carbon dioxide monitoring is necessary. This can only be achieved through more teaching and training directed towards nursing staff in casualty department. This will ensure that they know what is being requested in emergency situation.
Availability of etCO2 monitoring device on casualty and intensive care department. All the nursing staff should be aware of where these sampling connectors are stored.
Teaching and training of junior doctors who actually use the monitoring. The teaching sessions/study day on airway management in emergency situation can help raise awareness. Training in patient transfer (formal courses are available) may be helpful for novice doctors.
Reaudit the practice again and look for any positive changes in quality of clinical care with regards to use of end tidal carbon dioxide monitoring for rapid sequence induction and patient transfer.

References:

1. Caplan RA, Posner KL, Ward RJ. Adverse respiratory events in
anaesthesia: a closed claims analysis. Anesthesiology 1990; 72; 828-33.
2. Difficult airway society (DAS) guidelines.
3. S D Carley, C Gwinnutt, J Butler. Rapid sequence induction in the
emergency department: a strategy for failure. Emerg Med J 2002; 19:109-
113
4. Pearson S. The airway pipeline: How do you know where your ETT is?
Air Med J 22:42 - 46, 2003.
5. Tobias JD, Lynch A, Garrett J. Pediatric Emerg Care. 1996 Aug;
12(4):249-51.
6. The intensive care society (UK) guidelines.
7. Royal college of anaesthetists of UK guidelines.
8. The Association of Anaesthetists of great Briton and Ireland guidelines.