490 SECTION V Pediatric Critical Care Pulmonary doses of opiate medications, such as patient controlled analgesia (PCA) Currently, the use of capnography for monitoring a pa tient’s ventilatory status[.]
490 S E C T I O N V Pediatric Critical Care: Pulmonary CO2 (mm Hg) 50 Real-time Trend Real-time Trend 37 A CO2 (mm Hg) 50 37 B • Fig 43.8 (A) Increasing proximal end-tidal carbon dioxide (CO2) level (B) Rising baseline (Modified from Zwerneman K End-tidal carbon dioxide monitoring: a VITAL sign worth watching Crit Care Nurs Clin North Am 2006;18:217–225.) doses of opiate medications, such as patient-controlled analgesia (PCA) Currently, the use of capnography for monitoring a patient’s ventilatory status during procedural sedation or PCA use is recommended by the American Society of Anesthesia, The Joint Commission, the Anesthesia Patient Safety Foundation, and the Institute for Safe Medication Practices.63–67 Finally, Petco2 monitoring is becoming a routine monitoring parameter during cardiopulmonary resuscitation (CPR).56,61 Of all prehospital vital signs, Petco2 has been found to be the most predictive and consistent for mortality.68 Recent Advanced Cardiac Life Support (ACLS) and PALS guidelines recommend using capnography to monitor the effectiveness of chest compressions during CPR.69 A sudden decrease in Petco2 is seen with loss of pulmonary blood flow in cardiac arrest Increasing Petco2 values generated during CPR are associated with chest compression depth and ventilation rate,70 and an acute rise in Petco2 exceeding 10 mm Hg is seen with return of spontaneous circulation (ROSC).71 Patients with ROSC after CPR have statistically higher levels of Petco2, suggesting better lung perfusion and cardiac output.72 Current guidelines suggest achieving a threshold of 10 to 15 mm Hg to ensure adequate delivery of chest compressions, although an average Petco2 level of 25 mm Hg was found in patients with ROSC in a recent systematic review and metaanalysis.72–74 Ongoing studies will further elucidate Petco2 goals and may be used to predict outcomes in the resuscitation setting Transcutaneous Monitoring Transcutaneous measurements reflect both gas exchange and skin perfusion The development of portable, miniaturized electrodes led to the use of this technology to continuously measure both oxygen and CO2 tension transcutaneously In this technique, a probe composed of a heater, an electrode, and a thermistor is applied to the patient’s skin The skin is warmed and softened to improve diffusion and permeability This step also causes capillaries to dilate, resulting in better approximation of arterial oxygen values This technology works under the assumption that transcutaneous values reflect those from the arterial circulation Heating the skin allows more rapid diffusion of both oxygen and CO2 from the subcutaneous tissues to the surface of the electrode However, the heating affects both tissue and blood by decreasing oxygen solubility, shifting the oxyhemoglobin dissociation curve to the right and dilating local arterioles Temperatures of 44°C to 45°C increase diffusion and prevent vasoconstriction in the local area of the skin.75 Oxygen Monitoring Transcutaneous Clarke electrodes measure oxygen tension in a local segment of the heated skin Because skin is the organ most responsive to adrenomedullary-induced vasoconstriction, local oxygen tension may not be the same in all skin segments or other tissues In essence, transcutaneous oxygen tension (TcPo2) is only an indirect reflection of arterial oxygen tension; it is more directly related to local tissue perfusion and oxygenation There are several limitations and disadvantages that limit the use of transcutaneous monitoring to the newborn population Skin thickness increases with age, making transcutaneous measurements less predictable Electrode placement must be changed every to hours to prevent thermal injury to the site of measurement or when readings become unstable A thermal-neutral environment to limit peripheral vasoconstriction increases the correlation between transcutaneous and arterial tensions Finally, the electrode membranes must be calibrated before each use and each change of measurement site, and comparison with arterial blood gases is necessary However, displaying TcPo2 has been shown to result in less time spent hyperoxemic and less time spent hypoxemic than displaying the Spo2, which may be particularly useful in infants.76 Because of these limitations and the ease of application of pulse oximetry and Petco2 monitoring, transcutaneous oxygen monitoring has nearly been replaced by other monitoring methods Carbon Dioxide Monitoring Transcutaneous CO2 tension using a Stowe-Severinghaus electrode has been widely used in the neonatal population to approximate Paco2 Transcutaneous CO2 values parallel but consistently overestimate Paco2 values in hemodynamically stable neonates and adults.77 The difference in arterial and transcutaneous values reflects accumulation of CO2 in the tissues as a result of inadequate perfusion Transcutaneous monitoring of CO2 more closely approximates arterial CO2 tension in infants and children who are experiencing respiratory failure than does Petco2.78–80 This technology is also useful in settings in which nonconventional forms of ventilation (high-frequency ventilation) preclude the use of end-tidal monitoring CHAPTER 43 Noninvasive Respiratory Monitoring and Assessment of Gas Exchange Conclusion In the PICU, early identification of physiologic changes and decompensation can have a substantial effect on patient safety and outcomes Through modern technology, clinicians are now able to recognize changes in patients’ oxygenation and ventilation status more rapidly than ever before using noninvasive measures For these reasons, noninvasive monitors, such as pulse oximetry and capnometry, are standards of care in the pediatric critical care environment Therefore, it is important to understand key clinical and technical issues that determine how these instruments can be used most effectively Concerns for complications related to invasive monitors will continue to drive the search for newer and better devices for noninvasive physiologic monitoring Advances have been made in the technology of pulse oximeters, allowing measurements of all types of hemoglobin—including dyshemoglobins and total hemoglobin—with less artifact resulting from patient movement, which is a vital consideration in the PICU patient population Newer technologies—such as NIRS, reflectance spectroscopy, and transcutaneous monitoring—provide additional data that can be used to guide care of critically ill children While these advances in technology are promising, they each have downfalls and unique sources of error Clinicians must 491 remember the importance of basic vital sign monitoring and clinical observation, such as heart rate, respiratory rate, temperature, fluid balance, and physical examination findings Key References Bickler P, Feiner J, Rollins M, Meng L Tissue Oximetry and Clinical Outcomes Anesth Analg 2017;124(1):72-82 Langhan ML, Ching K, Northrup V, et al A randomized controlled trial of capnography 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A randomised crossover study of saturation versus transcutaneous monitoring Arch Dis Child Fetal Neonatal Ed 2008;93(5):F347-F350 77 Tremper KK, Shoemaker WC, Shippy CR, Nolan LS Transcutaneous PCO2 monitoring on adult patients in the ICU and the operating room Critical Care Med 1981;9(10):752-755 78 Tobias JD Transcutaneous carbon dioxide monitoring in infants and children Paediatr Anaesth 2009;19(5):434-444 79 Tobias JD, Meyer DJ Noninvasive monitoring of carbon dioxide during respiratory failure in toddlers and infants: end-tidal versus transcutaneous carbon dioxide Anesth Analg 1997;85(1):55-58 80 Urbano J, Cruzado V, Lopez-Herce J, del Castillo J, Bellon JM, Carrillo A Accuracy of three transcutaneous carbon dioxide monitors in critically ill children Pediatr Pulmonol 2010;45(5):481-486 e3 Abstract: Pulse oximetry and capnometry have significantly affected the practice of critical care medicine and are now standards of care Pulse oximetry allows for earlier detection of hypoxemia than clinical examination and aids the clinician in the identification and treatment of hypoxemia, with possible prevention of serious complications Capnography can be a good global indicator of the patient’s condition and can detect alveolar hypoventilation before changes detected by pulse oximetry Both pulse oximetry and capnometry are useful tools for close monitoring of a patient’s oxygenation and ventilation status However, critical care providers should be aware of limitations of these monitoring modalities Key words: Noninvasive, oximetry, capnography, oxygenation, ventilation, respiratory ... space/tidal volume ratio in respiratory failure Chest 1987;92(5):832-835 The full reference list for this chapter is available at ExpertConsult.com e1 References Rosenberg DI, Moss MM Guidelines and... a human volunteer study Anesthesiology 2006;105(5):892-897 37 Coulange M, Barthelemy A, Hug F, Thierry AL, De Haro L Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning