The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts


Utility of a Respiratory Care Practitioner during Procedural Sedation

Brady Scott RRT, RCP, Jhaymie Cappiello RRT, RCP, John Davies RRT, RCP, Neil MacIntyre, MD Duke University Medical Center, Durham, NC.

BACKGROUND: Sedation and analgesia outside the supervision of an anesthesiologist has become increasingly popular. Advances in pharmacological agents, monitoring techniques, and specialization of healthcare professionals have helped make procedural sedation (PS) a more accepted practice. The ability of Respiratory Care Practitioners (RCP's) to assist in the evaluation and prevention of hypoventilation and hypoxia has established them as a valuable team member for many institutions' PS practice. In 2001, the American Society of Anesthesiologists recommended in their "Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists" that 1: a designated individual should be present to monitor the patient throughout the procedure and 2: automated apnea monitoring (exhaled CO2) may decrease the risks during both moderate and deep sedation. In response to this, our emergency department has instituted the use of RCP's and spontaneous capnographic monitoring in our PS policy. Since our institution's PS protocol incorporates RCP's, we sought to evaluate the safety and efficacy of this service.

METHOD: IRB approval for a retrospective chart review was obtained. Over an eight month period, 52 patients ranging in ages from 3 to 88 received procedural sedation via protocol in the emergency department. Medications used included ketamine, versed, fentanyl, morphine, etomidate, and ativan. The RCP monitored pulse oximetry, respiratory rate, heart rate, airway patency, and ETCO2 via nasal prongs. The Modified Ramsey Scale (MRS) measured depth of sedation. Adverse events were predetermined to be cyanosis, loss of airway, bradycardia (HR< 60), hypotension (systolic < 80mmhg), gastric reflux, aspiration, use of reversal agents, and need for intubation.

RESULT: The number of patients in each category of the MRS (1-6) is indicated below. All of the procedures were successfully performed to the attending physician's satisfaction. One patient reached a MRS of 6 and required a brief period of bag-valve-mask ventilation. No other adverse events or outcomes were noted.

MRS Pre Procedure During Procedure Post Procedure
1 3 0 1
2 49 3 42
3 0 18 7
4 0 18 2
5 0 12 0
6 0 1 0

Pre PS ETCO2 Post PS ETCO2

High 56 59
Low 20 20
Mean 36 41

CONCLUSION: The PS protocol appears to be effective in terms of patient safety. We believe the presence of the RCP at the bedside allowed for an acceptable MRS score for the procedure and prevented adverse side effects.

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Utility of a Respiratory Care Practitioner during Procedural Sedation