A case against capnographic monitoring as a standard of care

Benefits and harms of capnography during procedures involving moderate sedation: A rapid review and meta-analysis

BACKGROUND

Patient safety is a priority in dentistry. Evaluating the benefits and harms associated with the addition of capnography to standard monitoring during moderate sedation for adult patients in the dental practice setting is needed.

TYPES OF STUDIES REVIEWED

The authors used rapid review methodology to identify relevant systematic reviews, which they updated through a systematic search by using the same search strategy as the identified reviews. The authors searched PubMed and Google Scholar and through the references of the identified systematic reviews, which yielded 2,892 studies. Inclusion criteria were that the article was available in English, was original research in adult humans who had undergone moderate procedural sedation, and involved comparing standard monitoring with the addition of capnography.

RESULTS

Sixteen studies were eligible, involving 3,866 adults undergoing procedural sedation. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the evidence and rate it as being of moderate to low quality because of high risk of bias and heterogeneous effects for the outcomes of hypoxemia and adverse respiratory events. Capnography had higher sensitivity to detect adverse respiratory events than did standard monitoring alone (0.92; 95% confidence interval, 0.65 to 0.99) and may reduce the risk of developing hypoxemia by 31% (risk ratio, 0.69; 95% confidence interval, 0.57 to 0.82). Capnography did not affect the risk of developing serious adverse events, procedure time, sedation quality, or patient satisfaction.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Adding capnography to standard monitoring of adults during moderate sedation may reduce the risk of developing hypoxemia, increase detection of adverse respiratory events, and is not associated with additional harms. These findings suggest routine use of capnography during moderate sedation has the potential to reduce adverse anesthetic outcomes in dental practice.

Capnography Detection Using Nasal Cannula Is Superior to Modified Nasal Hood in an Open Airway System: A Randomized Controlled Trial

PURPOSE

The nasal cannula and modified nasal hood are methods used by oral and maxillofacial surgeons to detect expired carbon dioxide during procedural sedation in an open airway system. The purpose of this study was to compare the accuracy of the detection of expired carbon dioxide between the nasal cannula and modified nasal hood.

MATERIALS AND METHODS

The authors designed a parallel-group randomized controlled trial to compare the nasal cannula and modified nasal hood. Patients presenting to the authors' institution for outpatient oral and maxillofacial surgery (OMS) using intravenous deep sedation or general anesthesia were randomized to have capnography detection by the modified nasal hood or the nasal cannula. The primary outcome variable was the percentage of accurately captured breaths, as determined by the average number of capnography waveforms per auscultated breath using a precordial stethoscope. The 2 groups were compared using t test.

RESULTS

Fifty patients were screened for enrollment in the study. Twenty-five patients were randomized to the nasal cannula group and 25 patients were randomized to the modified nasal hood group. The proportion of accurate waveforms, recorded as a percentage of total breaths, was 95.7 ± 4.7% for the nasal cannula and 75.8 ± 14.1% for the modified nasal hood (P < .0001).

CONCLUSIONS

When used for capnography for procedural sedation in an open airway system for routine OMS, the nasal cannula accurately recorded more breaths than the modified nasal hood.

Providing Anesthesia in the Oral and Maxillofacial Surgery Office: A Look Back, Where We Are Now and a Look Ahead

Throughout its development the practice of oral and maxillofacial surgery has been richly associated with the provision of anesthetic services. Dentists and particularly oral and maxillofacial surgeons have advanced the science associated with anesthesia especially in the outpatient setting. This article will look back on the development of anesthesia as it relates to oral and maxillofacial surgery, discuss the current mode of anesthesia in the oral surgeon's practice and look ahead to what innovations are advancing this field.

Assessment of Alteration in Capnometry Monitoring during Intravenous Sedation with Midazolam for Oral Surgical Procedures

INTRODUCTION

Capnography is routinely used for monitoring of patients subjected to sedation for different surgical procedures. There is still paucity of data highlighting the capnographic assessment of patients on midazolam sedation undergoing oral surgical procedures. Hence, we planned the present study to assess the alterations occurring in the end-tidal carbon dioxide (ETCO₂) values monitored during intravenous (IV) sedation with midazolam during various oral surgical procedures.

MATERIALS AND METHODS

The present study included assessment of alteration in ETCO₂ values occurring during oral surgical procedure. After meeting the inclusion and exclusion criteria, a total of 40 participants were included in the present study. Pulse oximeter with capnograph (EmcoMeditek Pvt., Ltd., India) device was used for assessment of respiratory rate (RR) and ETCO₂ values. The mean of 12 readings over a period of 1 minute before the starting of first infusion was referred to as baseline time. By evaluating the first four readings at an interval of 15 seconds during the 1st minute of infusion, we obtained the 1 minute average reading. All the data were compiled and recorded and assessed by the Statistical Package for the Social Sciences (SPSS) software.

RESULTS

A total of 40 participants were included, out of which, 20 were males and 20 were females. At the baseline time, mean value of ETCO₂ was 31 mm Hg, while mean value of oxygen saturation (SpO₂) was 36%. Out of total 40 participants, 15 showed the presence of respiratory depression. Out of these 15 participants, ETCO₂ changes from baseline were observed in 13 participants.

CONCLUSION

No oxygen should be delivered, unless until required, to the healthy participants undergoing dental sedation procedures, for marinating the sensitivity of pulse oximetry during assessment of respiratory depression.

CLINICAL SIGNIFICANCE

In patients undergoing sedation procedures, various monitoring techniques should be employed as respiratory depression is a commonly encountered risk factor.

Evaluation of the SEDline to improve the safety and efficiency of conscious sedation

Brain function monitors have improved safety and efficiency in general anesthesia; however, they have not been adequately tested for guiding conscious sedation for periodontal surgical procedures. This study evaluated the patient state index (PSI) obtained from the SEDline monitor (Sedline Inc., San Diego, CA) to determine its capacity to improve the safety and efficiency of intravenous conscious sedation during outpatient periodontal surgery. Twenty-one patients at the periodontics clinic of Baylor College of Dentistry were admitted to the study in 2009 and sedated to a moderate level using midazolam and fentanyl during periodontal surgery. The PSI monitoring was blinded from the clinician, and the following data were collected: vital signs, Ramsay sedation scale (RSS), medications administered, adverse events, PSI, electroencephalography, and the patients' perspective through visual analogue scales. The data were correlated to evaluate the PSI's ability to assess the level of sedation. Results showed that the RSS and PSI did not correlate (r = -0.25) unless high values associated with electromyographical (EMG) activity were corrected (r = -0.47). Oxygen desaturation did not correlate with the PSI (r = -0.08). Satisfaction (r = -0.57) and amnesia (r = -0.55) both increased as the average PSI decreased. In conclusion, within the limits of this study, PSI appears to correlate with amnesia, allowing a practitioner to titrate medications to that effect. It did not provide advance warning of adverse events and had inherent inaccuracies due to EMG activity during oral surgery. The PSI has the potential to increase safety and efficiency in conscious sedation but requires further development to eliminate EMG activity from confounding the score.