通气监测标准.ppt
http://www.100md.com
参见附件(33KB)。
Standards for Ventilation Monitoring
John H. Eichhorn, M.D.
Professor and Chairman
Department of Anesthesiology
University of Mississippi SOM/
Medical Center
Jackson, Mississippi
History of Ventilation Monitoring
?Classic teaching of the stethoscope on the chest or trachea
? "Malpractice crisis" of late 1970's focused attention on anesthesia accidents
?Harvard Risk Management Committee analyzed 1976-84 events:
Vast majority of preventable accidents due to failure of ventilation: spontaneous or controlled
History of Ventilation
Monitoring - 2
? Original 1985 "Harvard monitoring standards" mandated continuous monitoring of ventilation during "any administration of anesthesia:"
- "Palpation or observation of the reservoir breathing bag, auscultation of breath sounds, monitoring of respiratory gases such as end-tidal carbon dioxide, or monitoring of respiratory gas flow.Monitoring end-tidal carbon dioxide is an emerging standard and is strongly preferred."
History of Ventilation Monitoring -3
? ASA original Standards for Basic Intraoperative Monitoring - 1986
- "Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. While qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds may be adequate, quantitative monitoring of the CO2 content and/or volume of expired gas is encouraged."
History of Ventilation Monitoring - 4
? ASA original Standards for Basic Intraoperative Monitoring - 1986:
-"When an endotracheal tube is inserted, its correct positioning in the trachea must be verified by clinical assessment and by identification of carbon dioxide in the expired gas.End-tidal CO2 analysis, in use from the time of endotracheal tube placement, is encouraged."
- "During regional anesthesia and monitored anesthesia care, the adequacy of ventilation shall be evaluated, at least, by continual observation of qualitative clinical signs."
History of Ventilation Monitoring - 5
? "Early warning" of ventilatory compromise from capnography emphasized; desaturation on pulse oximeter actually a very late finding
? ASA standards - 1992 further modification: capnography "...is strongly encouraged."
? ASA standards - 1995 major change: capnography mandatory on intubated patients
History of Ventilation Monitoring - 6
? Later addition of reference to capnography with use of laryngeal mask as well as OET
? ASA standards - 1998 amendment: capnography mandate expanded to include face mask general anesthesia:
- "Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful.Continual monitoring for the presence or expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment...."
ASA Guidelines for Office-Based Anesthesia
? Adherence to "Standards for Basic Anesthetic Monitoring" expected
? "...appropriate anesthesia apparatus and equipment which allow monitoring consistent with ASA Standards for Basic Anesthetic Monitoring..." required
? No specific attention to distinction of sedation vs. anesthesia
Sedation vs. Anesthesia
? Published formal standards for monitoring during sedation do not exist
? Widely varying institutional policies and procedures, especially regarding supposed differing levels of sedation
? JCAHO, AAAASF, and AAAHC all interested and concerned
DeFacto Standard of Care for Sedation
? Ventilation monitoring concept widely recognized
? Some type of ventilation monitoring for sedated patient clearly is a de facto standard of care
? Method of meeting this standard is up to practitioner, so far
DeFacto Standard of Care for Sedation -2
? Using continuous electronic monitoring such as capnography (as an extension of the human senses) for sedated patients makes sense just as it did for intubated patients in 1985
? Cost of capnography trivial compared to even merely responding to one mal-practice lawsuit from an adverse event
DeFacto Standard of Care for Sedation -3
? With the advances in capnography for sedation patients and the resulting ability to apply electronic monitoring in addition to simple observation of breathing for everyone, it makes sense, both clinically and for standard of care, to use capnography to monitor sedation patients.
Standards for Ventilation Monitoring
John H. Eichhorn, M.D.
Professor and Chairman
Department of Anesthesiology
University of Mississippi SOM/
Medical Center
Jackson, Mississippi
History of Ventilation Monitoring
?Classic teaching of the stethoscope on the chest or trachea
? "Malpractice crisis" of late 1970's focused attention on anesthesia accidents
?Harvard Risk Management Committee analyzed 1976-84 events:
Vast majority of preventable accidents due to failure of ventilation: spontaneous or controlled
History of Ventilation
Monitoring - 2
? Original 1985 "Harvard monitoring standards" mandated continuous monitoring of ventilation during "any administration of anesthesia:"
- "Palpation or observation of the reservoir breathing bag, auscultation of breath sounds, monitoring of respiratory gases such as end-tidal carbon dioxide, or monitoring of respiratory gas flow.Monitoring end-tidal carbon dioxide is an emerging standard and is strongly preferred."
History of Ventilation Monitoring -3
? ASA original Standards for Basic Intraoperative Monitoring - 1986
- "Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. While qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds may be adequate, quantitative monitoring of the CO2 content and/or volume of expired gas is encouraged."
History of Ventilation Monitoring - 4
? ASA original Standards for Basic Intraoperative Monitoring - 1986:
-"When an endotracheal tube is inserted, its correct positioning in the trachea must be verified by clinical assessment and by identification of carbon dioxide in the expired gas.End-tidal CO2 analysis, in use from the time of endotracheal tube placement, is encouraged."
- "During regional anesthesia and monitored anesthesia care, the adequacy of ventilation shall be evaluated, at least, by continual observation of qualitative clinical signs."
History of Ventilation Monitoring - 5
? "Early warning" of ventilatory compromise from capnography emphasized; desaturation on pulse oximeter actually a very late finding
? ASA standards - 1992 further modification: capnography "...is strongly encouraged."
? ASA standards - 1995 major change: capnography mandatory on intubated patients
History of Ventilation Monitoring - 6
? Later addition of reference to capnography with use of laryngeal mask as well as OET
? ASA standards - 1998 amendment: capnography mandate expanded to include face mask general anesthesia:
- "Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful.Continual monitoring for the presence or expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment...."
ASA Guidelines for Office-Based Anesthesia
? Adherence to "Standards for Basic Anesthetic Monitoring" expected
? "...appropriate anesthesia apparatus and equipment which allow monitoring consistent with ASA Standards for Basic Anesthetic Monitoring..." required
? No specific attention to distinction of sedation vs. anesthesia
Sedation vs. Anesthesia
? Published formal standards for monitoring during sedation do not exist
? Widely varying institutional policies and procedures, especially regarding supposed differing levels of sedation
? JCAHO, AAAASF, and AAAHC all interested and concerned
DeFacto Standard of Care for Sedation
? Ventilation monitoring concept widely recognized
? Some type of ventilation monitoring for sedated patient clearly is a de facto standard of care
? Method of meeting this standard is up to practitioner, so far
DeFacto Standard of Care for Sedation -2
? Using continuous electronic monitoring such as capnography (as an extension of the human senses) for sedated patients makes sense just as it did for intubated patients in 1985
? Cost of capnography trivial compared to even merely responding to one mal-practice lawsuit from an adverse event
DeFacto Standard of Care for Sedation -3
? With the advances in capnography for sedation patients and the resulting ability to apply electronic monitoring in addition to simple observation of breathing for everyone, it makes sense, both clinically and for standard of care, to use capnography to monitor sedation patients.
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