Clinical update

Clinical update: monitoring during anaesthesia and recovery

New standards on patient monitoring require hospitals to provide capnography throughout anaesthesia

New standards on patient monitoring require hospitals to provide capnography throughout anaesthesia

Picture: Medtronic

Essential facts

Respiratory compromise is a critical perioperative complication associated with increased costs and poor outcomes. It is common, costly, deadly and, most importantly, preventable.

Respiratory compromise consists of respiratory insufficiency, failure and arrest, and can dramatically increase the likelihood of adverse outcomes for patients.

A recent report from The Royal College of Anaesthetists and Difficult Airway Society discovered that airway deaths and significant patient harm occurs outside the operating room, particularly in intensive care units and emergency departments.

Up to 74% of these deaths could have been prevented by monitoring patients using capnography.

What’s new?

The Association of Anaesthetists of Great Britain & Ireland has published updated standards in patient monitoring.

These standards mandate hospitals to work towards using capnography for all anaesthetist-led sedation to improve patient safety and help prevent respiratory compromise.

Previously, capnography was required in the monitoring of patients only while they were under anaesthesia in the operating room. Now, hospital departments must provide capnography monitoring throughout the whole period of anaesthesia, from induction to full recovery of consciousness.

Hospitals are recommended to set up overall sedation committees to implement protocols and ensure the new standards are followed. This means that staff will be required to be proficient in capnography and to use capnography devices whenever sedation occurs.

Causes and risk factors

Respiratory compromise occurs when the body cannot perform the necessary gas exchange between oxygen and carbon dioxide.

Specific lung diseases and conditions, such as chronic obstructive pulmonary disease, pneumonia and pulmonary embolism, put patients at higher risk of respiratory compromise.

Conditions affecting the nerves and muscles that control breathing, such as spinal cord injuries and muscular dystrophy, also present a higher risk.

Some sedative and analgesic drugs can reduce ventilatory drive. This may be associated with sedation for interventional or diagnostic procedures performed in theatres, catheterisation labs, and radiology and endoscopy departments.

Reduced ventilatory drive may also be associated with regular sedation and analgesia administered in ward environments, and critical care and emergency departments.

Because almost every patient will receive some sort of sedation or analgesia at some point during their hospital stays, the iatrogenic risk is considerably high.

Signs and symptoms

These depend on the underlying cause, and the levels of oxygen and carbon dioxide in the blood.

Signs and symptoms of respiratory compromise include dyspnoea, hypoxia, hypoventilation, hypopnoea, hyperpnoea, hypercapnia, confusion and anxiety.

In extreme situations, respiratory compromise can lead to cyanosis, altered consciousness and arrhythmias.

Helping patients

Capnography should be used to monitor patients undergoing moderate or deep sedation, as well as those using ventilation. This is the fastest technology for identifying respiratory compromise.

If respiratory compromise develops, proper clinical history taking and physical examination will help identify the cause.

Nurses should always work as part of multidisciplinary teams to reverse the identified cause.

If you are involved in caring for patients receiving sedation and/or analgesia:

  • Familiarise yourself with current standards and guidelines.
  • Seek appropriate training that develops your knowledge and skills.
  • Ensure the clinical environment is safe and consider consultancy to ensure compliance.
Expert comment

Andreia Trigo is director of SedateUK and a clinical nurse specialist in pain


‘In a considerable number of departments, professionals still practise sedation without the required training or adhering to minimum essential standards of monitoring. This is unacceptable. It is costly for hospitals and exposes patients to unnecessary risks, such as respiratory compromise.

‘To improve patient safety it is vital that nurses always monitor patients undergoing any form of sedation.

‘It is also crucial that nurses follow updated monitoring standards and undergo specific sedation training so they are competent and up to date.

‘Standards, guidance, equipment, data and training on sedation are readily available for nurses at all levels.

‘It may be that some departments still need to invest in capnographs, sedation training and adequate nursing ratios. However, early warnings of respiratory compromise give nurses opportunities to provide care sooner, which reduces risk and saves time, money and lives.’


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