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
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?
Transcript: Long ago, Greek philosophers believed we had tiny internal combustion engines inside our bodies that produced “smoke,” or capnos. It turns out, the Greeks were correct. So how did the Greeks get it right? Capnography is... ...the measurement of carbon dioxide concentrations in exhaled air. When would we use capnography at WFR? Capnography 101 WFR Medic Recert 2013 At sea level 1 atmosphere of pressure is equivalent to 760 millimeters of mercury (mmHg). SpO2 waveform is in the second channel EtCO2 waveform is in the third channel Ventilation Carbon dioxide from metabolism EtCO2 measures exhaled CO2 at point of exit Reflects change in ventilation within 10 seconds So why is CO2 measured as a pressure? Oxygenation and Ventilation In air (including exhaled air) there is more than 1 gas. Since 760 is the same as 1 atmosphere then you take the amount (percentage) of a gas and then multiply it by 760 and you get the amount of pressure the specific gas has. Oxygenation and Ventilation Oxygenation Oxygen for metabolism SpO2 measures % of O2 in RBC Reflects change in oxygenation within 5 minutes For instance if there is 20.84% oxygen in the air we breath you would take. 20.84% X 760= 15838 or 158 mmHg Do the same with exhaled CO2 in a healthy person. 5.2% X 760= 3952 or 40 mmHg
Transcript: Paramedic Science Personal Protection Cardiopulmonary Review Capnography Infection Control Mandates Pathogens Measuring a vital life sustaining process Scene Safety Stress EMT - Basic By Keith Rademachir Capnography As an EMT, very few situations can command our attention as quickly as a patient with an emergency involving the cardiopulmonary system. We can find many clues from looking at our patient that they are in danger from a cardiopulmonary disruption. However, at times these signs can be subtle and easy to miss in the midst of a complicated scene. Enter capnography, a quick and reliable way to measure exhaled co2 in our patients. This sounds like such a simple thing and it is, BUT, have you ever actually thought what this means in terms of physiology and what our patient facing internally? Lets talk about that and you will see exactly how important that one simple thing can be. Cardiopulmonary System Review Anatomy Physiology Pathogens A pathogen is a bacterium, virus, or other microorganism that can cause disease. These are commonly broken down into two types. These are bloodborne and airborne. Bloodborne pathogens may be present in ANY bodily fluid and are most often spread through direct contact. Airborne pathogens are most often spread through moisture droplets in the air (such as following a cough or sneeze). Hepatitis is an infection that causes inflammation of the liver. There are several types with the most common being B and C. Hepatitis is NOT a curable disease. While it can be fatal, People can also live long and occasionally symptom free lives. Hepatitis can live for Several days in dried bodily fluids. Hepatitis B can be vaccinated against. However, there is currently NO vaccination for Hepatitis C. Hepatitis HIV / Aids Human Immunodeficiency Virus (commonly known as HIV) is a bloodborne pathogen. There is no cure for HIV and over time it can develop into AIDS. At this point it actively attacks the immune system. Aids patients generally die from infections such as flu or pneumonia since they have a severely weekened immune system. Tuberculosis Tuberculosis is a highly contagious airborne pathogen. It is an infection of the lungs. Symptoms include cough for more than 3 weeks, night sweats, fever and lethargy. Tuberculosis is curable. Once a known exposure occurs treatment with antibiotics will begin irregardless of symptoms and typically lasts for a year. PPE when treating a known TB patient should include an N-95 respirator or HEPA mask. Influenza Influenza is an extremely contagious infection. There are many different strains of influenza and most have a available anual vaccine. Influenza is an airborne pathogen and is spread at a distance in droplets when an infected person coughs or sneezes. People with depressed immune system the elderly and pediatrics are especially susceptible to influenza. PPE should include a surgical style mask. OSHA Mandates for InfectionControl The Occupational Safety and Health Administration (OSHA) is responsible for enacting and enforcing mandates related to infection control. These mandates include the provision of PPE and other methods of control. Also mandated is an exposure plan to be put into effect in the case of an exposure to a pathogen. These mandates apply to all EMS providers due to the high risk of exposure.
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.
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?
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
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.
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