Anaesthetists have been using gas analysers for years (see here). Access to this equipment in other resuscitation environments will improve patient safety.
We support availability of gas analysers (oxygen analysers & capnography) in the following locations:
– theatre recovery
– emergency resus bays
– all arrest trolleys
– neonatal resuscitation trolleys
We support availability of capnography for all paramedics.
These stories illustrate the benefits of broader use of gas analysers:
Pre-oxygenation by the Emergency Physician
After 5 minutes of pre-oxygenation the emergency physician was unable to intubate. She was surprised just how quickly the patient desaturated and felt the stress this caused clouded her judgement. The patient eventually obtained a surgical airway.
The emergency physician later noticed the bag valve mask used for pre-oxygenation wasn’t connected to an oxygen source.
An anaesthetist who attended couldn’t help thinking how end-tidal oxygen monitoring would have helped assess pre-oxygenation effectiveness.
The patients carotid artery was severed performing the surgical airway and he died 4 days later.
Night registrar on the ward
A junior registrar was called to review a patient who’d desaturated on the ward. The combination of sedative medications with a morphine PCA had led to the patients deterioration.
The registrar attempted airway support and then bag mask ventilation which seemed difficult. After inserting a guedel the registrar thought he’d established a patent airway but couldn’t be sure – the patient’s oxygen saturations failed to improve quickly.
Attempted intubation was difficult. After auscultating the chest and stomach the registrar wasn’t convinced of endotracheal tube placement. Despite obtaining the support of senior doctors the patient died in intensive care the following day.
The outcome may have been very different if the registrar had access to capnography – he may have realised he’d established a patent airway during bag valve mask ventilation.
A similar case is described (see here)
Failed resuscitation of newborn
On delivery the midwife noted the newborn was floppy and pale. The paediatrician helped with resuscitation, initially administering air, then increasing amounts of oxygen as conditions weren’t improving. The causes of deterioration filed through the paediatricians mind – did the newborn have an undiagnosed circulatory condition, a major hole in the heart? With further deterioration the paediatrian decided to intubate. Despite all resuscitative attempts the newborn died.
Staff later learned that recent renovations in what was considered an unrelated part of the hospital had actually caused a mix up in oxygen and nitrous oxide pipelines. All standard procedures had been followed but as the oxygen outlet wasn’t deemed part of the renovation there was no mandate to assess it.
The anaesthetist knew if the neonatal resuscitation trolley had a mixed gas analyser like the one on his anaesthetic machine the error would have been picked up before the newborn got anywhere near the oxygen outlet. Despite the pipeline error the adverse event would have been avoided…..
Numerous pipeline errors have caused patient deaths and morbidity (see here).
Paramedic Airway Support
A morbidly obese pedestrian was involved in a motor vehicle accident. The paramedics were unable to intubate him. They’d inserted a laryngeal mask airway and attempted to ventilate. They were never completely sure of airway patency – it was difficult to auscultate his lungs because of his body habitus. Despite resuscitative attempts on arrival in emergency the patient died.
An anaesthetist who attended resuscitation in the emergency department felt the paramedics suffered from a lack of access to capnography. With this vital piece of monitoring they may have had the feedback required to establish an airway and the outcome could have been different.
All paramedics should be granted access to capnography (see here).
Gas analysis monitors are very intuitive – it would take little to educate those unfamiliar with them.
We would be extremely interested in your feedback and support – provide anecdotes, viewpoints, educational resources, and anything else you believe may help.
Some colleges recognise the need to implement gas analysers outside theatre (see here).
We’re communicating with governing bodies and will continue to update this post as we obtain new information.
Support the Implementation of Gas Monitoring in Areas of Resuscitation #SIGMAR16