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Correspondence |

Patient-Focused Sedation and Analgesia FREE TO VIEW

David Lain, PhD
Author and Funding Information

Oridion Capnography, Needham, MA

Correspondence to: David Lain, PhD, Oridion Capnography, 160 Gould St, Suite 205, Needham, MA 02494; e-mail: david.lain@oridion.com



Chest. 2008;134(2):468-469. doi:10.1378/chest.08-0513
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To the Editor:

The article by Sessler and Varney,1 “Patient-Focused Sedation and Analgesia in the ICU” (February 2008), was brilliant. For decades, the concerns of sedation and analgesia in the ICU have troubled me. During the past year, I have been extensively investigating patient risk specific to sedation and analgesia in multiple environments.

Beyond the long-term psychological outcomes, there is the matter of the pharmaceutical impact on respiratory depression. During mechanical ventilation, breathing is controlled. Aside from the weaning complexities that may result from sedation and analgesia, there remains the burden of managing postextubation hazards specific to respiratory depression. Once extubated, patients’ pain and anxiety remain and are therapeutically treated.

Certainly, patients are closely monitored in the ICU after mechanical ventilation. Pulse oximetry and ECG monitoring are ubiquitous to the critical care arena. Nevertheless, respiratory depression is a risk during sedation even in the ICU.

In a report presented at the Society for Technology in Anesthesia Annual Congress held in San Diego this January, researchers from the University of Alabama at Birmingham presented a metaanalysis2 of patient safety during sedation and analgesia. They discovered these patients are at 28-times greater risk for having unrecognized respiratory depression when not monitored using capnography. They added that pulse oximetry alone might be dangerous.

It is important to manage pain in the ICU. Our tools for assessing pain and thus reducing it are part of a strategy to improve the total health-care experience for the patient. Ventilation monitoring after extubation should incorporate the diagnostic systems available to the ICU care provider. As an early warning to respiratory depression, during sedation and analgesia, capnography is a faster indicator than pulse oximetry.34 Furthermore, relying on respiratory rate alone without a measure of the adequacy of ventilation, such as exhaled carbon dioxide levels, is of limited clinical value.5

Capnography is indispensable as a rapid monitor of respiratory depression that can be pharmaceutically imposed.6 Many bedside monitors allow caregivers to use capnography in the ICU. During critical care stays, patients may benefit from early indicators of impending respiratory depression; capnography is the fastest method to alert caregivers of respiratory depression. So long as we provide sedation and analgesia in the ICU, certain patients will remain in jeopardy for respiratory depression, and strategies can be in place to reduce that risk. Thank you Drs. Sessler and Varney for your timely and thought-provoking article.

The author has no conflict of interest to disclose.

Sessler, CN, Varney, K (2008) Patient-focused sedation and analgesia in the ICU.Chest133,552-569. [PubMed] [CrossRef]
 
Waugh JB, Khodneva Y, Epps CA. Monitoring to improve ventilation safety during sedation and analgesia. Presented at Society for Technology in Anesthesia, January 2008, San Diego, CA.
 
Waugh, JB, Stanley, SA, Beckett, C, et al Comparison of apnea detection by pulse oximetry versus capnography [abstract].Respir Care2007;52,1556
 
Bazin, J-E Detection of respiratory depression prior to evidence of hypoxemia in procedural sedation [abstract].Respir Care2007;52,1568
 
Folke, M, Cernerud, L, Ekstrom, M, et al Critical review of non-invasive respiratory monitoring in medical care.Med Biol Eng Comput2003;41,377-383. [PubMed]
 
McCarter, T, Shaik, Z, Scarfo, K, et al End-tidal carbon dioxide monitoring in patient controlled analgesia [abstract].Respir Care2007;52,1567
 

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References

Sessler, CN, Varney, K (2008) Patient-focused sedation and analgesia in the ICU.Chest133,552-569. [PubMed] [CrossRef]
 
Waugh JB, Khodneva Y, Epps CA. Monitoring to improve ventilation safety during sedation and analgesia. Presented at Society for Technology in Anesthesia, January 2008, San Diego, CA.
 
Waugh, JB, Stanley, SA, Beckett, C, et al Comparison of apnea detection by pulse oximetry versus capnography [abstract].Respir Care2007;52,1556
 
Bazin, J-E Detection of respiratory depression prior to evidence of hypoxemia in procedural sedation [abstract].Respir Care2007;52,1568
 
Folke, M, Cernerud, L, Ekstrom, M, et al Critical review of non-invasive respiratory monitoring in medical care.Med Biol Eng Comput2003;41,377-383. [PubMed]
 
McCarter, T, Shaik, Z, Scarfo, K, et al End-tidal carbon dioxide monitoring in patient controlled analgesia [abstract].Respir Care2007;52,1567
 
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