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Kathy Yoder
continuous pulseox with PCA

We're in the process of converting all policies to Mosby. The question of whether or not a high risk patient (ie.BMI>35, asthma etc.) with a PCA needs to be on continuous pulseox has come up.  Does anyone know if this is a standard of care?

Pulse ox or end tidal CO2 or

Pulse ox or end tidal CO2 or other respiratory monitoring systems are not officially recommended for PCA in the current issues of any standards or guidelines that I know of. The INS standards are currently under revision and I do not know what they will recommend about these practices. But this issue has become a keen interest of mine recently as my 75 year old uncle had a serious adverse event with a PCA just a few weeks ago. On the evening of surgery following a lap chlole and spleenectomy, a new syringe of morphine was put into the machine at 11 pm and he went to sleep at 11:30 pm. He was found the next morning at 6 am, not breathing and only a palpable BP of 30. Fortunately he recovered but the hospital has not given him any explanation or apology for the event. The more I discuss this, the more events I hear about. So in my opinion, some form of monitoring respiratory function is necessary for patient safety. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

CO2 monitoring

I'm on the ASPMN listserve and I think the consensus is that decreased oxygen saturation is a late sign.  Just about everyone agrees that there is a fairly predictable sequence as patients become overmedicated over time:  confusion, then progressive somnolence, then resp rate decrease/shallow resp and so on.  Some are doing CO2 monitoring rather than pulse ox.  But all agree that nothing can really replace the assessment of the nurse during interaction with the pt.  I've contacted some folks to see if ASPMN is working on a position paper for this.  I'll let you know.

Chris Pasero response

This is from Chris Pasero, who with Margo McCaffery is revising their Pain: Clinical Manual for its 3rd edition.  Sounds like she is also on the ASPMN taskforce working on this issue:

"No, it is not standard of care to place all patients receiving PCA on pulse oximetry or capnography. And yes, the ASPMN task force is finishing its work on the guideline now. We will recommend that institutions identify high risk patients and consider the use of technology in them during opioid therapies, such as PCA. (Remember that pulse ox is not recommended as a means of monitoring opioid-induced respiratory depression in patients receiving supplemental oxygen.) We will also stress the importance of nurse assessment of respiratory status and sedation levels (using a reliable and valid sedation scale) and responding appropriately (decrease dose and increase monitoring) when increasing sedation is detected. Multimodal analgesia is important as well so that the lowest effective dose can be given. These are the things we will be recommending in our next book as well. You may forward this to the list if you want. Chris"

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