Capnography versus standard monitoring for emergency department procedural sedation and analgesia.
BACKGROUND
Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting.


OBJECTIVE
To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA.


METHODS
We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015.


METHODS
We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA.


METHODS
Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models.


RESULTS
We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time.


CONCLUSIONS
There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.
Department of Emergency Medicine, North York General Hospital, 4001 Leslie St, Toronto, Ontario, Canada, M2K 1E1.|Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada, M5B 1W8.
Brian F
BF
Wall
Department of Emergency Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax Infirmary, 1796 Summer Street, Halifax, NS, Canada, B3H 3A7.
Kirk
K
Magee
Department of Emergency Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax Infirmary, 1796 Summer Street, Halifax, NS, Canada, B3H 3A7.
Samuel G
SG
Campbell
Faculty of Pharmaceutical Sciences, The University of British Columbia, 2146 East Mall, Vancouver, BC, Canada, V6T 1Z3.|Department of Emergency Medicine, The University of British Columbia, Vancouver, Canada.
Peter J
PJ
Zed
D000698:Analgesia; D001795:Blood Pressure Determination; D019296:Capnography / Q000379:methods*; D004636:Emergency Service, Hospital; D004638:Emergency Treatment / Q000009:adverse effects / Q000379:methods*; D006339:Heart Rate; D006801:Humans; D007022:Hypotension / Q000517:prevention & control; D000860:Hypoxia / Q000517:prevention & control; D008991:Monitoring, Physiologic / Q000379:methods*; D010092:Oximetry; D011015:Pneumonia, Aspiration / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic; D014839:Vomiting / Q000517:prevention & control