title: Advanced Monitoring Is Associated with Fewer Alarm Events During Planned Moderate Procedure-Related Sedation: A 2-Part Pilot Trial.
abstract: BACKGROUND
  Diagnostic and interventional procedures are often facilitated by moderate procedure-related sedation. Many studies support the overall safety of this sedation; however, adverse cardiovascular and respiratory events are reported in up to 70% of these procedures, more frequently in very young, very old, or sicker patients. Monitoring with pulse oximetry may underreport hypoventilation during sedation, particularly if supplemental oxygen is provided. Capnometry may result in false alarms during sedation when patients mouth breathe or displace sampling devices. Advanced monitor use during sedation may allow event detection before complications develop. This 2-part pilot study used advanced monitors during planned moderate sedation to (1) determine incidences of desaturation, low respiratory rate, and deeper than intended sedation alarm events; and (2) determine whether advanced monitor use is associated with fewer alarm events.
  
  
  METHODS
  Adult patients undergoing scheduled gastroenterology or interventional radiology procedures with planned moderate sedation given by dedicated sedation nurses under the direction of procedural physicians (procedural sedation team) were monitored per standard protocols (electrocardiography blood pressure, pulse oximetry, and capnometry) and advanced monitors (acoustic respiratory monitoring and processed electroencephalograpy). Data were collected to computers for analysis. Advanced monitor parameters were not visible to teams in part 1 (standard) but were visible to teams in part 2 (advanced). Alarm events were defined as desaturation-SpO2 ≤92%; respiratory depression, acoustic respiratory rate ≤8 breaths per minute, and deeper than intended sedation, indicated by processed electroencephalograpy. The number of alarm events was compared.
  
  
  RESULTS
  Of 100 patients enrolled, 10 were excluded for data collection computer malfunction or consent withdrawal. Data were analyzed from 90 patients (44 standard and 46 advanced). Advanced had fewer total alarms than standard (Wilcoxon-Mann-Whitney = 2.073, P = 0.038; Wilcoxon-Mann-Whitney odds, 1.67; 95% confidence interval [CI], 1.04-2.88). Similar numbers of standard and advanced had ≥1 alarm event (Wald difference, -10.2%; 95% CI, -26.4% to 7.0%; P = 0.237). Fewer advanced patients had ≥1 respiratory depression event (Wald difference, -22.1%; 95% CI, -40.9% to -2.4%; P = 0.036) or ≥1 desaturation event (Wald difference, -24.2%; 95% CI, -42.8% to -3.6%; P = 0.021); but there was no significant difference in deeper than intended sedation events (Wald difference, -1.38%; 95% CI, -20.21% to 17.49%; P = 0.887).
  
  
  CONCLUSIONS
  Use of advanced monitoring parameters during planned moderate sedation was associated with fewer alarm events, patients experiencing desaturation, and patients experiencing respiratory depression alarm events. This pilot study suggests that further study into the safety and outcome impacts of advanced monitoring during procedure-related sedation is warranted.
authors.affiliation: From the *Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California; †Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California; and ‡Department of Radiology, Loma Linda University School of Medicine, Loma Linda, California.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Applegate
authors.forename: John
authors.initials: J
authors.lastname: Lenart
authors.forename: Mathew
authors.initials: M
authors.lastname: Malkin
authors.forename: Minhthy N
authors.initials: MN
authors.lastname: Meineke
authors.forename: Silvana
authors.initials: S
authors.lastname: Qoshlli
authors.forename: Monica
authors.initials: M
authors.lastname: Neumann
authors.forename: J Paul
authors.initials: JP
authors.lastname: Jacobson
authors.forename: Alison
authors.initials: A
authors.lastname: Kruger
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Ching
authors.forename: Mohammad
authors.initials: M
authors.lastname: Hassanian
authors.forename: Michael
authors.initials: M
authors.lastname: Um
mesh_terms: D056902:Clinical Alarms / Q000592:standards*; D016292:Procedural Sedation / Q000009:adverse effects / Q000379:methods*; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D015642:Radiology, Interventional
references.citation: Chest. 2004 Nov;126(5):1552-8
references.pmid: 15539726
references.citation: Anesthesiology. 2002 Apr;96(4):1004-17
references.pmid: 11964611
references.citation: Can J Anaesth. 2015 Jan;62(1):54-67
references.pmid: 25323121
references.citation: Br J Anaesth. 2014 Jul;113(1):195-7
references.pmid: 24942722
references.citation: J Neurosurg Anesthesiol. 2013 Apr;25(2):191-6
references.pmid: 23269088
references.citation: Anesth Analg. 2015 Feb;120(2):342-8
references.pmid: 25390281
references.citation: Anesth Analg. 2011 Jan;112(1):78-83
references.pmid: 20966440
references.citation: Anesth Analg. 2013 Jul;117(1):69-75
references.pmid: 23632055
references.citation: JAMA. 2014 Mar 26;311(12):1199-200
references.pmid: 24590296
references.citation: Intensive Care Med. 2004 Feb;30(2):213-6
references.pmid: 14673519
references.citation: Anesth Analg. 2014 Dec;119(6):1307-14
references.pmid: 25025587
references.citation: Sentinel Event Alert. 2013 Apr 8;(50):1-3
references.pmid: 23767076
references.citation: Singapore Med J. 2013 Apr;54(4):212-5
references.pmid: 23624448
references.citation: World J Gastroenterol. 2013 Jan 28;19(4):463-81
references.pmid: 23382625
references.citation: World J Gastrointest Endosc. 2014 Mar 16;6(3):82-7
references.pmid: 24634712
references.citation: World J Gastrointest Endosc. 2013 Nov 16;5(11):527-33
references.pmid: 24255744
references.citation: Ann Pharmacother. 2007 Feb;41(2):255-66
references.pmid: 17299011
references.citation: J Clin Gastroenterol. 2010 Mar;44(3):161-6
references.pmid: 20042871
references.citation: J Clin Monit Comput. 2014 Dec;28(6):561-6
references.pmid: 24420342
references.citation: Proc (Bayl Univ Med Cent). 2011 Jul;24(3):200-4
references.pmid: 21738291
references.citation: Am J Gastroenterol. 2012 Aug;107(8):1205-12
references.pmid: 22641306
references.citation: Digestion. 2011;84(1):37-45
references.pmid: 21304242
references.citation: Acad Emerg Med. 2005 Jun;12(6):508-13
references.pmid: 15930401
references.citation: Ann Emerg Med. 2014 Feb;63(2):247-58.e18
references.pmid: 24438649
references.citation: J Clin Anesth. 2011 May;23(3):189-96
references.pmid: 21497076
references.citation: Br J Anaesth. 2012 May;108(5):872-5
references.pmid: 22323525
references.citation: Am J Gastroenterol. 2012 Oct;107(10):1495-501; quiz 1494, 1502
references.pmid: 22869323
references.citation: Dig Dis Sci. 2009 May;54(5):1035-40
references.pmid: 19003534
references.citation: Anesth Analg. 2013 Sep;117(3):699-710
references.pmid: 23456667
references.citation: Anesth Analg. 2009 Mar;108(3):795-804
references.pmid: 19224786
references.citation: Anesthesiology. 2009 Sep;111(3):609-15
references.pmid: 19672177
references.citation: Gastrointest Endosc. 2008 May;67(6):910-23
references.pmid: 18440381
references.citation: Curr Opin Anaesthesiol. 2010 Aug;23(4):494-9
references.pmid: 20585246
references.citation: Paediatr Anaesth. 2013 Dec;23(12):1166-73
references.pmid: 24033591
references.citation: Anaesthesia. 2015 Jan;70(1):26-31
references.pmid: 25040754
references.citation: J Bronchology Interv Pulmonol. 2014 Jul;21(3):188-91
references.pmid: 24992125
references.citation: Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44
references.pmid: 12421743
references.citation: J Electrocardiol. 2012 Nov-Dec;45(6):588-91
references.pmid: 23022300
references.citation: Proc (Bayl Univ Med Cent). 2014 Jan;27(1):12-5
references.pmid: 24381393
references.citation: Z Gastroenterol. 2013 Jun;51(6):568-72
references.pmid: 23740356
references.citation: Br Med J. 1974 Jun 22;2(5920):656-9
references.pmid: 4835444
references.citation: J Patient Saf. 2014 Sep 8;:null
references.pmid: 25203503
references.citation: J Pain Symptom Manage. 2001 Aug;22(2):672-87
references.pmid: 11495714
references.citation: Am J Gastroenterol. 2005 Dec;100(12):2689-95
references.pmid: 16393221
references.citation: Anaesthesia. 2013 Aug;68(8):804-10
references.pmid: 23745968
references.citation: Gastrointest Endosc. 2007 Feb;65(2):213-21
references.pmid: 17258979
references.citation: Anesth Analg. 2004 Aug;99(2):379-82, table of contents
references.pmid: 15271710
references.citation: Curr Opin Anaesthesiol. 2010 Aug;23(4):523-31
references.pmid: 20531171
references.citation: Anesthesiology. 2013 Jan;118(1):192-201
references.pmid: 23221867
references.citation: Anesth Analg. 2013 Sep;117(3):537-8
references.pmid: 23966647
references.citation: Gastrointest Endosc. 2011 Oct;74(4):885-96
references.pmid: 21951478
references.citation: Gastrointest Endosc Clin N Am. 2015 Jan;25(1):147-58
references.pmid: 25442964
references.citation: Best Pract Res Clin Anaesthesiol. 2006 Mar;20(1):121-8
references.pmid: 16634419
references.citation: Curr Opin Anaesthesiol. 2009 Aug;22(4):502-8
references.pmid: 19506473
references.citation: J Clin Monit. 1996 Mar;12(2):155-9
references.pmid: 8823636
references.citation: Gastrointest Endosc. 2007 Jul;66(1):27-34
references.pmid: 17591470
references.citation: Crit Care Med. 2010 Feb;38(2):451-6
references.pmid: 20016379