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Introduction

Changes in patient populations, along with economic and practical considerations, have led to an overall increase in patient acuity on the general care floor (GCF). Despite the presence of higher risk patients, current GCF surveillance is often limited to isolated spot checks of core vital signs, such as heart rate, respiratory rate, blood pressure and temperature, with such observations often limited to every 4 hours, which leaves patients unmonitored 96% of the time.1 Therefore, these patients may be placed at increased risk for respiratory compromise.

What is respiratory compromise?

Respiratory compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency and failure, respiratory arrest or death, but in which specific interventions (continuous monitoring and therapies) might prevent or mitigate decompensation.2

MONITORING FOR RESPIRATORY COMPROMISE

Changes in respiratory vital signs that accompany respiratory compromise often precede in-hospital deterioration and are associated with increased mortality due to the high likelihood of decompensation into respiratory insufficiency and failure, as well as respiratory arrest. 2,3,4,5

Moreover, many in-hospital declines may be preventable with better respiratory monitoring and early intervention.6,7,8 Continuous monitoring of respiratory function and patient evaluation for respiratory insufficiency, arrest and failure can alert medical professionals to conditions which could lead to adverse events.  Therefore, implementing better strategies for prevention, monitoring for and management of respiratory abnormalities in patients could lead to improved patient outcomes and decreased costs.

Respiratory Compromise Among Patients on the General Care Floor
26.8% Percentage of acute respiratory compromise events that occure on the GFC9
41% Percentage of patients on the GCF receiveing opioids who suffer bradynea10
50% Percentage of patients with respiratory compromise on the GCF for whom intervention was delayed by greater than 30 minutes11
12 hours Median time of delayed intervention for patients suffering respiratory compromise on the GCF11
2.10 Odds ration for mortality in patients with delayed intervention on the GCF following respiratory compromise11

The Anesthesia Patient Safety Foundation (APSF), American Society for Pain Management (ASPMN), American Society of Anesthesiologists (ASA), and the Joint Commission currently recommend patient monitoring system of both oxygenation and ventilation with pulse oximetry and capnography in postoperative patients at-risk for respiratory compromise.12,13,14,15 Recommendations from the APSF specifically state that continuous electronic monitoring of oxygenation and ventilation should be available and considered for all patients and would reduce the likelihood of unrecognized clinically significant opioid-induced depression of ventilation in the postoperative period.12

Respiratory Compromise Among Patients on the General Care Floor

REAL-WORLD EVIDENCE FOR RESPIRATORY COMPROMISE PREVENTION IN PROCEDURAL SEDATION

Incidence of respiratory adverse events in moderate to deep procedural sedation is often underestimated, still reported in published clinical studies16 and its consequences may, even if rarely, lead to death.16

The outcomes pledge program by Medtronic will help you measure the incidence of adverse events in your own setting, with your own clinical team and your own protocols and assess the impact of capnography monitoring on the prevention of such events.

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CONTINUOUS ETCO2

Continuous Respiratory Rate Monitoring

CONTINUOUS SPO2 MONITORING

REMOTE PATIENT MONITORING

RECOMMENDED PRODUCTS

Nellcor™ pulse oximetry for continuous SpO2

Provides easy access to the status of a patient's oxygenation and respiration.

Proven Technology, State-of-the-Art Design.

Microstream™ Capnography Monitors

May provide an early warning of respiratory compromise. 17,18,19

Vital Sync™ Monitoring and Clinical Decision Support (CDS) Solution

Provides the tools you need to support real-time protocol driven clinical decisions, create workflow efficiencies, and control costs.

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Resources

  • 1. Weinger, M. B., & Lee, L. A. No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression. APSF Newsletter. 2011;26(2):21.
  • 2. Respiratory Compromise Insitute. http://www.respiratorycompromise.org/. 2017
  • 3. Barfod, C., Lauritzen, M. M., Danker, J. K., et al. Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study. Scand J Trauma Resusc Emerg Med. 2012;20:28.
  • 4. Buist, M., Bernard, S., Nguyen, T. V., Moore, G., & Anderson, J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004;62(2):137-141.
  • 5. Chaboyer, W., Thalib, L., Foster, M., Ball, C., & Richards, B. Predictors of adverse events in patients after discharge from the intensive care unit. Am J Crit Care. 2008;17(3):255-263; quiz 264.
  • 6. Lee, L. A., Caplan, R. A., Stephens, L. S., et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122(3):659-665.
  • 7. Quach, J. L., Downey, A. W., Haase, M., Haase-Fielitz, A., Jones, D., & Bellomo, R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care. 2008;23(3):325-331.
  • 8. Taenzer, A. H., Pyke, J. B., McGrath, S. P., & Blike, G. T. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112(2):282-287.
  • 9. Wang, H. E., Abella, B. S., & Callaway, C. W. Risk of cardiopulmonary arrest after acute respiratory compromise in hospitalized patients. Resuscitation. 2008;79(2):234-240.
  • 10. Overdyk, F. J., Carter, R., Maddox, R. R., Callura, J., Herrin, A. E., & Henriquez, C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007;105(2):412-418.
  • 11. Quach, J. L., Downey, A. W., Haase, M., Haase-Fielitz, A., Jones, D., & Bellomo, R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care. 2008;23(3):325-331.
  • 12. Anesthesia Patient Safety Foundation. Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period. Conclusions and Recommendations. https://www.apsf.org/announcements.php?id=7. 2011.
  • 13. ASA Standards for Basic Anesthetic Monitoring, Committee of Origin: Standards and Practice Parameters (Approved by the ASA House of Delegates on October 21, 1986, and last amended on October 20, 2010 with an effective date of July 1, 2011) - Viewed 3-21-11 at http://www.asahq.org/sitecore%20modules/web/~/media/modules/digital%20briefcase%20apps/asa%20practice%20management/standards%20guidelines%20statements/anesthesia%20care/standards-for-basic-anesthetic-monitoring.pdf.
  • 14. Jarzyna, D., Jungquist, C. R., Pasero, C., et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145 e110.
  • 15. The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;849(8):1-5.
  • 16. Leslie K, Allen ML, Hessian EC, Peyton PJ, Kasza J, Courtney A, et al. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: A prospective cohort study. Br J Anaesth. 2017;118(1):90–9. https://pubmed.ncbi.nlm.nih.gov/28039246/
  • 17. Cacho, G., Perez-Calle, J. L., Barbado, A., Lledo, J. L., Ojea, R., & Fernandez-Rodriguez, C. M. Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig. 2010;102(2):86-89.
  • 18. Maddox, R. R., Oglesby, H., Williams, C. K., Fields, M., & Danello, S. (2008). Continuous Respiratory Monitoring and a "Smart" Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period.
  • 19. Overdyk, F. J., Carter, R., Maddox, R. R., Callura, J., Herrin, A. E., & Henriquez, C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007;105(2):412-418.
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