Broader use of gas analysers will save lives.

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

Thank you.

11 thoughts on “Broader use of gas analysers will save lives.

  1. I would love to have access to end tidal oxygen monitoring in the prehospital world to assess adequacy of preoxygenation. I am not aware of any monitor designed for prehospital use that incorporates it however.

    It is time we started demanding this from the device manufacturers.

    Alan Garner
    PS and I don’t have it in my ED either where we only intubate critically ill people!

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    1. Lifepack 12s and later have the capacity for both nasal capnography and in-line after intubation. Zolls can do it as well (http://www.zoll.com/medical-products/defibrillators/r-series/etco2/.) In the US medics often have routine capnography on the ambulance, but it can be missing from the ED and even the ICU!

      I have asked several intensivists why we don’t routinely monitor end tidal w other vital signs in ICU patients and the only coherent answer I’ve been given is “it’s unreliable” (unlike automated blood pressures, oral and axillary temperatures, SaO2, and reported respiratory rates). Can’t help thinking the real reason is more:

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      1. Completely agree – I thought when I started watching the link they’d be singing ‘If I were a rich man’ – then I’d be rattling on about the fact it has little to do with cost.

        Unfortunately you’re very likely to be right – it’s ‘TRADITION’. ‘This is the way we’ve always done it and we’ve never had a problem’. What this really means is ‘we’ve never seen our problems’ – sadly this is due to lack of transparency in error reporting.

        We should strive to improve our work environments for patient safety. Change is always difficult – let’s rise to this challenge for the wellbeing of our patients.

        Thank you for your entertaining comment.

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  2. “This is the way we’ve always done it and we’ve never had a problem.”

    Yes, there’s a lot of death and pain trailing in the wake of that statement, isn’t there?

    Better reporting is absolutely needed. I also think we should study in more detail the psychological dynamics that make it hard to improve practice. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Because what is our great fear in medicine? Hurting people. Not being good enough. And when we change a process for the better it inevitably implies that our PREVIOUS way of doing things was (at least relatively) harmful. To make a minor change for the better, we might have to accept we have been hurting people, maybe killing people (or putting them at risk of death) for years, even decades!

    Another disturbing (but very natural) ego-protective attitude I’ve seen is when doctors reject innovations that make their carefully-honed skills less relevant. If you are a wizard at landmark-based central lines, do you embrace ultrasound? If you have honed your skills with DL with hundreds or thousands of intubations, how do you feel about a Glidescope? And I don’t mean just choosing the tool you’re most expert with — I’m talking about when senior doctors actively oppose or denigrate methods which are safer and/or more successful — not just for themselves but for their learners and the system as a whole too — because (I suspect) the innovation makes their own deft skill with the old tools less important.

    How do we overcome these dynamics? Better reporting is surely a vital part of it, but there is more work to do.

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    1. Completely agree.

      There are other issues that prevent or slow change implementation – including ‘Bystander Effect’: even when sufficient medical staff want change there are so many governing groups involved in effecting change – we suffer ‘diffusion of responsibility’.

      Thank you again for your insightful comments.

      Like

  3. In case 1:
    The obvious safety issue is that the one intubating was an emergency physiscian instead of the one true airway specialist, an anaesthetist.

    The emergency physicians have limited airway expertise and training.

    What are your thoughts on this? Is this not something that should be adressed? The increase in safety would be substantially larger than when introducing things such as EtO2.

    Like

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