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Capnography

Transcript: Incorporating Capnography as a Standard of Care in High-Risk Patients Stakeholders The measurement of exhaled CO2 in partial pressure (35-45 mmHg) Wave patterns detecting partial pressure or ETCO2 concentration captured by capnogram Greg Miller, Medtronic Strategic Alliance Clinical Consultant, stresses importance of capnography nursing policy and algorithm in decreasing RRTs On N4, Phillips monitors not utilized to full potential Several RRTs observed since March 2016 related to respiratory decline. N4 equipped with eight Phillips modules Between ICU and DOU, 30 Phillips modules with ETCO2 capability. Capnography not utilized in every intubated patient Average use of ABG kit/month from Aug 2015-July 2016: 302, with 457 ABG kits used July 2016 Health Care Provider Education through In-Services Training is FREE and offered by Microstream 3 days out of the week in 30 minute training sessions Patient Education Algorithm for consistent use of capnography Implementation of Nursing Policy Marvelyn Ardoña, Brooke Colquhoun, Leila Coronado Patients, caregivers, patient advocacy groups Providers Taxpayers Employers Shareholders Policymakers Represents the partial pressure of CO2 at the end of expiration Measured by capnography using a CO2 nasal cannula SpO2 and ETCO2 ETCO2 Concentration of CO2 Measures ventilation, diffusion, and perfusion Detects hypoventilation immediately Represents an EARLY warning of changes Should be used in conjunction with a pulse oximeter Sample Algorithm Internal Evidence Population: Patients at risk for respiratory depression; those with ARDS, asthma, COPD, CHF, pneumonia, sleep apnea, bronchitis, receiving supplemental oxygen, and post-operative non-intubated patients utilizing PCA pumps for the deliverance of morphine or dilaudid Intervention: Implementation of capnography monitoring through utilization of Microstream O2/CO2 Nasal FilterLine/CapnoLine H O2 that supplies oxygen while measuring CO2 output Comparators: Number of RRTs called on the unit using capnography as a “gold standard” with previous RRT data without ETCO2 monitoring Outcomes: Early detection of increased CO2 levels prior to decline in oxygen saturation, decrease in RRT calls and hospital costs, change in clinical management, and an increase in quality of patient care and satisfaction VALBHS purchased 82 Phillips MX800s at a cost of $1,783/monitor (without accessories) for a total of $146,206 According to Elizabeth Roman-Ingleton, the Phillips module purchase for VISN 22 was a multimillion dollar contract Oral/Nasal FilterLine/Long Term costs: 100/pack: $1,595.00 Nasal Only 25/pack: $385.00 Average length of stay on med/surg unit: $1,500-1,800/day Cost of an RRT: ABG kit costs: 100/pack: $252.47 X-ray costs Transfer to a unit with higher acuity of care (ICU/DOU) No devoted RRT team! RTs, RNs, MDs, pharmacists must leave their work/patients Microstream Smart CapnoLine EVIDENCE SpO2 Risk Factors: Age >60 or >50 in the post-op setting Comorbidities: ARDS, asthma, COPD, CHF, pneumonia, sleep apnea, bronchitis, receiving supplemental oxygen, and post-operative non-intubated patients utilizing PCA pumps for the deliverance of Morphine or Dilaudid Christina DiBernardo, RN, CNL Ryan Mercer, Medtronic Monitoring Systems Specialist Greg Miller, Medtronic Strategic Alliance Clinical Consultant Santiago Constantino, SPD Distribution Elizabeth Roman-Ingleton, RN, CIS/ARK Coordinator ETCO2 Nasal Cannula Pulse Oximetry Capnography Set dates for Greg Miller to hold Education and Training for health care providers Communicate internal and external evidence and obtain feedback from leadership, clinicians, and stakeholders Development of Nursing Policy for Capnography in Non-intubated Patients at risk for Respiratory Depression Further development of Algorithm for implementation of capnography monitoring O2 saturation Measures oxygenation Detects hypoxia Represents a LATE sign for action Reading may be normal even if patient not breathing Should not be used alone when monitoring cardiopulmonary status If pulse oximetry measures the percentage of O2 in the arterial blood, why do we care about ETCO2 in respiratory depressed patients? Adult/Intermediate CO2 Oral/Nasal Sampling Set with O2 Tubing Recruitment of Team and Stakeholders The PICO Approach EVIDENCE-BASED PRACTICE QUESTION Interdisciplinary Team Microstream CapnoLine External Evidence Expert Opinion: According to the Joint Commission (2004-2010), 58% of opioid-related events resulting in death or permanent loss of function were the result of improper monitoring.” – American Society of Pain Management According to the Canadian Agency for Drug and Technology Health in their health technology assessment, “there was a lower likelihood of hypoxemia when patients were monitored with capnography.” VHA’s integrated product team recommended that patient-controlled analgesia (PCA) pumps with an integrated ETCO2 monitor is pump of choice because “use of this technology could have prevented

Capnography

Transcript: RR = 18 Proprietary and Confidential Proprietary and Confidential “If we didn’t have the CO2 readings, we would have terminated efforts much sooner” A little-known device is shaking conventional wisdom for reviving people who suffer sudden cardiac arrest: People may be able to go much longer without a pulse than the 20 minutes previously believed. The capnograph, which measures carbon dioxide being expelled from the mouth of the patient, can tell rescuers when further efforts at cardiopulmonary resuscitation, or CPR, are futile or whether they should be continued. Results How to Grow your Business Phase 2 Phase 1 You need to have a knowledge base... a root system so to speak... Common Abnormal Waveforms Hypoventilation Increased CO2 with decreased RR Shallow Breathing Decreased CO2 until deep breath Partial Airway Obstruction Loss of alveolar plateau waveform is erratic patient may be snoring CO2 will decrease Opioid medications Pt may be talking No Breath Detected Knowledge Core Drive Why Capnography?

Capnography

Transcript: Carbon Dioxide is a waste product of cellular metabolism. How does this occur? What other waste products are produced? Water, heat and CO2 Remember that O2 and CO2 cross the alveolar membrane from higher to lower concentration. KEY POINT: As a patient exhales, the aveoli begin to shrink, cauing the concentration of CO2 to increase as the alveolar air begins to flow into the upper airways. When does MAXIMUM CO2 occur? At the end of expiration! What factors determine the amount of CO2 eliminated by the lungs? Amount of CO2 produced by cellular metabolism - strenuous excerise vs cardiac arrest Circulation - Is it being effectively carried? Consider shock & pulmonary embolism. Ventilation - what if no air is flowing in/out? How does Pulse oximetry differ from Capnography? Hemoglobin saturation at the cellular level vs. cellular waste product. KEY POINT: ETCO2 = expired end-tidal CO2 with normal values between 35mmHg - 45mmHG KEY POINT: A reading below 35mmHG = hyperventilation. WHY? KEY POINT: A reading above 45mmHg = hypoventilation Hypoventilation produces high levels of ETCO2 A known fact: Atmospheric level of CO2 is nearly zero (0.04% 21% O2 78% Nitrogen 1% other gases that include CO2 Let's take a look at a Normal Waveform Hey Jeff, in case your sugar is low, now is the time to hand it out! KEY POINT: Review the four phases of the respiratory cycle that are visualized in the capnograph. Phase 1 => Interval between A and B Phase 2 => Interval between B and C Phase 3 => Interval between C and D Phase 4 => Interval between D and E LIMITATIONS: Water droplets will affect sampler accuracy Ingestion of carbonated beverages may initially provide an elevated CO2 reading w/esophageal False Negative => tube placed properly but no CO2 produced. Suggest esophageal intubation. Might be PE, cardiac arrest or poor CPR Let's look at a few common waveforms! Capnography An instrument to measure the concentration of C02 in a sample of air.

Capnography

Transcript: Understanding It's Purpose Capnography 101 History Lesson History 1943 Standard of Care in the OR Karl Luft - Devloped CO2 measuring device - URAS: Ultra Rot Absorption Schreiber Anesthesiologists have used it 1860–1936 John Scott Haldane 1st described CO2 analysis 1970's 1991 Joint Commision Made it a standard for procedural sedation 2001 Adopted its use 2011 What is it Capnography Continuous recording of CO2 partial pressure in inspiratory and expiratory gases over TIME 2wo 4our Side Stream Inline Nasal Canula Devices 3hree Relationship of CO2 concentration to time is graphically represented by the CO2 waveform, or capnogram 1ne Non-invasive Low cost Rapid deployment Instant values No calculation BLS Accurate Topic 3 What does it looks like Chart Chart Timeline Timeline YEAR Topic 4 Benefits

Capnography

Transcript: Kacie Berry End Tidal Capnography Purpose Purpose Analyze the use of capnography compared to pulse oximetry for early detection of respiratory compromise in non-intubated patients undergoing gastrointestinal endoscopy (GIE) procedures under moderate sedation Authors Authors Jace Holton, CRNA Bryan Flattery, CRNA Publication Publication Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports Volume 14 Issue 12 Pages 38-47 December 2016 Moderate Sedation Moderate Sedation Article Says: "A drug-induced decrease in consciousness which still allows the individual undergoing sedation to respond to verbal commands and/or light tactile stimulation." -ASA Capnography What is capnography? A non-invasive, real-time measurement of inspiration and expiration of CO2 Written in mmHg Graphical waveform Cannula Breathing Pattern Current Practice Current practice Visual Assessment BP heart rate respiratory rate Pulse Oximetry O2 saturation How Ventilation Works Purpose Authors Authors Jace Holton, CRNA Bryan Flattery, CRNA Publication Publication Joanna Briggs Institute Case Study Purpose Authors Authors Jace Holton, CRNA Bryan Flattery, CRNA Publication Publication Joanna Briggs Institute Thoughts Purpose Authors Authors Jace Holton, CRNA Bryan Flattery, CRNA Publication Publication Joanna Briggs Institute Questions? Questions?

CAPNOGRAPHY

Transcript: - Used by anasthesiologists since 1970's -Standard of care in the OR since 1991 Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care. It is usually presented as a graph of expiratory CO2 (measured in millimeters of mercury, "mmHg") plotted against time, or, less commonly, but more usefully, expired volume. The plot may also show the inspired CO2, which is of interest when rebreathing systems are being used. FUTURE BREAKTHROUGH DISCUSSION FUNCTIONS AND APPLICATIONS design by Dóri Sirály for Prezi DIAGNOSTIC USAGE TECHNICAL OPERTAION -Oxygenation and ventilation are distinct physiologic functions that must be assessed in both intubated and spontaneously breathing patients. -Capnography became a routine part of anesthesia practice in Europe in the 1970s and in the United States in the 1980s. -Registered Nurses in critical care settings use capnography to determine if a nasogastric tube, which is used for feeding, has been placed in the esophagus as opposed to the trachea. HISTORICAL ACCOUNT MEDICAL SERVICES Capnography is a well-studied technology in anesthesia and has been used in the operating room for more than 35 years. USE IN Anesthesia CAPNOGRAPHY is the continuous non-invasive monitoring of exhaled carbon dioxide, and is essential for the measurement of adequacy of ventilation (breathing). By detecting changes in ventilation immediately as they happen, clinicians are alerted to potential respiratory problems before they become a serious threat to the patient. No other measure is as fast or effective as Capnography to monitor the breathing process and reduce the risk to patients of unrecognized, lifethreatening respiratory distress, which is the leading cause of preventable deaths in hospitals. CAPNOGRAPHY

PowerPoint Game Templates

Transcript: Example of a Jeopardy Template By: Laken Feeser and Rachel Chapman When creating without a template... http://www.edtechnetwork.com/powerpoint.html https://www.thebalance.com/free-family-feud-powerpoint-templates-1358184 Example of a Deal or No Deal Template PowerPoint Game Templates There are free templates for games such as jeopardy, wheel of fortune, and cash cab that can be downloaded online. However, some templates may cost more money depending on the complexity of the game. Classroom Games that Make Test Review and Memorization Fun! (n.d.). Retrieved February 17, 2017, from http://people.uncw.edu/ertzbergerj/msgames.htm Fisher, S. (n.d.). Customize a PowerPoint Game for Your Class with These Free Templates. Retrieved February 17, 2017, from https://www.thebalance.com/free-powerpoint-games-for-teachers-1358169 1. Users will begin with a lot of slides all with the same basic graphic design. 2. The, decide and create a series of questions that are to be asked during the game. 3. By hyper linking certain answers to different slides, the game jumps from slide to slide while playing the game. 4. This kind of setup is normally seen as a simple quiz show game. Example of a Wheel of Fortune Template https://www.teacherspayteachers.com/Product/Wheel-of-Riches-PowerPoint-Template-Plays-Just-Like-Wheel-of-Fortune-383606 Games can be made in order to make a fun and easy way to learn. Popular game templates include: Family Feud Millionaire Jeopardy and other quiz shows. http://www.free-power-point-templates.com/deal-powerpoint-template/ Quick video on template "Millionaire" PowerPoint Games Some games are easier to make compared to others If users are unsure whether or not downloading certain templates is safe, you can actually make your own game by just simply using PowerPoint. add logo here References Example of a Family Feud Template PowerPoint Games are a great way to introduce new concepts and ideas You can create a fun, competitive atmosphere with the use of different templates You can change and rearrange information to correlate with the topic or idea being discussed. Great with students, workers, family, etc. For example: With games like Jeopardy and Family Feud, players can pick practically any answers. The person who is running the game will have to have all of the answers in order to determine if players are correct or not. However, with a game like Who Wants to be a Millionaire, the players only have a choice between answers, A, B, C, or D. Therefore, when the player decides their answer, the person running the game clicks it, and the game will tell them whether they are right or wrong.

Capnography

Transcript: The End 1. Is there CO2 present? (any waveform) Normal 35-45mmHg Hypocapnea less than 35mm/Hg Hypercapnea more than 45 mm/Hg Air leak around ET tube Patient is blowing off more CO2 than is making during metabolism. Hyperventilation syndrome Esophageal intubation Blood does not return to the lungs to exchange gases. Uneven or "shark fin" plateau is uneven alveolar emptying. Curved plateaus are secondary to bronchospasm in conditions such as an asthma attack. Sedation wearing off from RSI. Patient attempting to breath on their own. C 0 metabolism is slowed in hypothermic state Problems with Intubation (compensation for metabolic conditions such as DKA) B 2. Look for rebreathing. You will see a breath to breath increase in the respiratory baseline. 4. Look at the alveolar expiratory plateau. Should be flat. Ventilatory failure blood pH drops below 7.35 causes problems with oxygen binding and off loading to cells. Normal 35-45mmHg Hypocapnea less than 35mm/Hg Hypercapnea more than 45 mm/Hg Esophageal intubation (BVM had forced some CO2 into the stomach. 5. Read the CO2 value. Hypothermia End Tidal CO2 monitoring Hypoperfusion Acidosis (Shock, hypotension, PE, CPR) 70 hypoventilation and respiratory failure leads to acidosis. D Evaluation process A more than 45 mm/Hg Hyperventilation end stage COPD patients may retain CO2 and still maintain normal acid base balance through kidneys. Hypoventilation 40 An ETCO2 value without a waveform is like a heart rate without an ECG Hypocapnea Normal Capnogram Hypercapnea E Alveoli empty at the same rate, therefore CO2 is eliminated at the same rate creating a square waveform. CO2 Retention less than 35 mm/Hg 3. Respiratory upstroke should be square.

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