Continuous Pulse Oximetry Research Articles

Safely doing less and the new AAP bronchiolitis guideline.

Since acute viral bronchiolitis is thus a self-limited disease of relatively good prognosis, the principle of primum non nocere should temper frustrated anxiety to do something—anything—to relieve severe dyspnea. Simple physical exhaustion may determine the fate of an infant laboring to meet his metabolic requirements for oxygen. His energies should not be frittered away by the annoyance of unnecessary or futile medications and procedures. Rest should be treasured. F. Howell Wright and Marc O. Beem1 It was 1965 when Drs F. Howell Wright and Marc O. Beem put forth this advice in the pages of Pediatrics . Nearly 50 years later, the publication of the 2014 American Academy of Pediatrics’ Clinical Practice Guideline on the Diagnosis, Management, and Prevention of Bronchiolitis2 reminds us just how little things have changed. Current evidence suggests that the sage advice of Drs Wright and Beem largely has been ignored.3,4 “Doing something” has trumped watchful waiting. Medications, tests, and procedures continue to be used profusely in spite of decades of research confirming their futility. In the updated 2014 guidelines, which include recommendations based on literature published since the last iteration, 10 of the 14 recommendations focus on tests or treatments to avoid. “Primum non nocere” appears to be the guiding principle behind these, with an emphasis on avoidance of interventions that lack a favorable risk-benefit ratio and with a focus on meaningful outcomes, such as hospitalization, length of stay, and symptom duration. Two recommendations in particular, 1 regarding trials of bronchodilators and 1 regarding continuous pulse oximetry, are … Address correspondence to Ricardo A. Quinonez, MD, Children’s Hospital of San Antonio, 315 N. San Saba St, Ste 1003, San Antonio, TX 78207. E-mail: quinonez{at}bcm.edu

Safety of Yoga in Pregnancy [37

BACKGROUND: Yoga is recognized for its potential to balance an individual's mental, physical, emotional, and spiritual state. Pregnant patients often ask physicians for permission to participate in yoga. The American Congress of Obstetricians and Gynecologists has no specific recommendations for yoga. The purpose of this study was to examine the safety of yoga in pregnancy. METHODS: Institutional review board approval was obtained. Pregnant women 18–42 years old with uncomplicated pregnancies were recruited. Patients were between 35 and 37 weeks of gestation. No yoga experience was required. A nonstress test (NST) was measured at the beginning and end of the yoga session. The participants assumed 26 yoga poses. In each posture, continuous fetal monitoring, tocometry, pulse oximetry, and vital signs were obtained. All sessions were attended by a certified yoga instructor and experienced obstetrician–gynecologist. RESULTS: A total of 30 women were enrolled; five were excluded for contractions at the initial NST. Twenty-five women completed the study. All participants completed the 26 poses. There were no significant changes in vital signs during the poses. All participants had reactive NSTs before and after the session. All fetal heart tracings demonstrated accelerations and variability, and no decelerations of the fetal heart tracing were seen. No patients had regular contractions during the session. There were no falls or injuries. CONCLUSION: No safety issues were identified. Vital signs, pulse oximetry, uterine tocometry, and fetal heart tracing remained reassuring in all patients in all postures. Yoga is a safe form of physical activity that physicians can recommend to their patients with uncomplicated pregnancies.

Using quality improvement to reduce continuous pulse oximetry use in children with wheezing.

Clinicians commonly use continuous pulse oximetry (CPOx) for hospitalized children with respiratory illnesses. The Choosing Wisely initiative recommended discontinuing CPOx for children on room air. We used quality improvement methods to reduce time on CPOx in patients with wheezing. Our project took place on 1 unit of a children's hospital. We developed consensus-based criteria for CPOx discontinuation. Interventions included education, a checklist used during nurse handoff, and discontinuation criteria incorporated into order sets. We collected data on a second unit where we did not actively intervene to assess for secular trends and negative consequences of shorter monitoring. We followed time until medically ready, ICU transfers, hospital revisits, and medical emergency team calls on both units. We tracked the impact of interventions by using run charts and statistical process control charts. Median time per week on CPOx after meeting goals decreased from 10.7 hours to 3.1 hours on the intervention unit. Median time per week on CPOx on the control unit decreased from 11.5 hours to 6.9 hours. There was no decrease in time until medically ready on either unit. The percentage of patients needing transfer, revisit, or medical emergency team call was similar on both units. With interventions focused on clarity and awareness of CPOx discontinuation criteria, we decreased time on CPOx; however, we saw no impact on time until medically ready. We expect that other centers could use analogous methods to standardize and reduce oxygen monitoring to meet Choosing Wisely recommendations.

A framework for reducing alarm fatigue on pediatric inpatient units.

On my (AK) first day on the patient floors as a medical student, I couldn’t help but notice the buzzing, beeping, cacophony of alarms that ostensibly indicated impending danger for just about every patient on the unit. I looked around, waiting for someone (a nurse, a doctor, anyone) to react. Yet thus far in my brief career, I’ve come to learn that most of the alarms I hear do not indicate emergencies, and in fact most do not warrant any clinical intervention at all. As a result, the buzzing and beeping fades into the background now. Physiologic monitor alarms are intentionally designed to alert clinicians immediately to any deviation from the norm, regardless of the quality of the signal or cause of the deviation.1 In theory, this design ensures that doctors and nurses will always be informed of physiologic changes to respond to important deterioration events quickly. However, we know that monitors generate frequent alarms (39–352 alarms per patient, per day)2–9 and that a high proportion are false, defined as not being actionable (>90% of pediatric ICU2,3 and >70% of adult intensive care alarms).6,7 The task of separating the true, actionable alarms from the false or nonactionable alarms falls to the clinicians responsible for responding to alarms, who in most settings are nurses. However, we rely on nurses for myriad other important responsibilities that we really care about, from administering antibiotics to a septic child, to discharging a kid with asthma so the mother can pick up the child’s inhaler before the pharmacy closes. Thus, nurses are forced to make difficult decisions on a nearly continuous basis about whether to respond to alarms from different patients or to continue with the tasks at hand, assuming that the alarms do not …

Evidence-Based Protocols to Guide Pulse Oximetry and Oxygen Weaning in Inpatient Children with Asthma and Bronchiolitis: A Pilot Project

Nurses', respiratory therapists' (RTs), and physicians' concerns about oxygen weaning practices and pulse oximetry use in healthy children during inpatient admissions prompted this multidisciplinary evidence-based project. A nurse-led inter-professional team found lack of consistent oxygen weaning practices and lack of guidelines for nurses or RTs regarding pulse oximetry use with children admitted for acute respiratory illness. The team created and piloted evidence-based oxygen weaning and pulse oximetry protocols. After a 6 month pilot, children in the pilot had shorter length of stay, time on oxygen, and time on continuous pulse oximetry. Protocols improved patient outcomes and decreased associated charges.

Blood oxygen equilibration time after cessation of supplemental oxygen in chronic respiratory disease.

Measurement of the arterial partial pressure of oxygen (PaO2 ) while breathing air is an informative investigation in patients with hypoxaemia due to chronic respiratory disease, but there are a lack of published data on the time needed for blood oxygen levels to equilibrate after cessation of supplemental oxygen (O2 ) in such patients. To determine the blood oxygen equilibration time after cessation of O2 and thereby provide guidance on best timing of baseline arterial blood gas analysis in this population. Medically stable subjects with chronic respiratory disease were administered O2 at a constant concentration. Continuous pulse oximetry was recorded from before cessation of O2 to beyond the point of oxygen saturation (SpO2 ) equilibration. Data were fitted to an exponential decay model. Blood oxygen equilibration time was defined as the t90, the time taken for SpO2 to fall 90% of the difference between initial (on O2 ) and final (on air) values. Eighty-two (82) subjects with a mean age of 66 years were included. The largest diagnostic category was chronic obstructive pulmonary disease (37), followed by interstitial lung disease (15) and bronchiectasis (12). The median t90 was 6 min 18 s (interquartile range: 4 min 32 s-10 min 30 s). The 95th centile t90 value was 20 min. In the majority of patients with chronic respiratory disease, a time delay of 20 min between cessation of supplemental O2 and PaO2 measurement allows confidence that the result is a true baseline value.

Multicenter study of the safety and effects of magnetic resonance imaging in patients with coronary sinus left ventricular pacing leads.

Magnetic resonance imaging (MRI) in patients with left ventricular (LV) leads may cause tissue or lead heating, dislodgment, venous damage, or lead dysfunction. The purpose of this study was to determine the safety of MRI in patients with LV pacing leads. Prospective data on patients with coronary sinus LV leads undergoing clinically indicated MRI at 3 institutions were collected. Patients were not pacemaker-dependent. Scans were performed under pacing nurse, technician, radiologist, and physicist supervision using continuous vital sign, pulse oximetry, and ECG monitoring and a 1.5-T scanner with specific absorption rate <1.5 W/kg. Devices were interrogated pre- and post-MRI, programmed to asynchronous or inhibition mode with tachyarrhythmia therapies off (if present), and reprogrammed to their original settings post-MRI. MRI scans (n = 42) were performed in 40 patients with non-MRI conditional LV leads between 2005 and 2013 (mean age 67 ± 9 years, n = 16 [40%] women, median lead implant duration 740 days with interquartile range 125-1173 days). MRIs were performed on the head/neck/spine (n = 35 [83%]), lower extremities (n = 4 [10%]), chest (n = 2 [5%]), and abdomen (n = 1 [2%]). There were no overall differences in pre- and post-MRI interrogation LV lead sensing (12.4 ± 6.2 mV vs 12.9 ± 6.7 mV, P = .38), impedance (724 ± 294 Ω vs 718 ± 312 Ω, P = .67), or threshold (1.4 ± 1.1 V vs 1.4 ± 1.0 V, P = .91). No individual LV lead changes required intervention. MRI scanning was performed safely in non-pacemaker-dependent patients with coronary sinus LV leads who were carefully monitored during imaging without clinically significant adverse effect on LV lead function.

Outpatient management of home oxygen for bronchiolitis.

Home O2 has been shown to reduce hospitalizations for bronchiolitis but data on outpatient management of home O2 are lacking. We aim to describe outpatient management and challenges to home O2 for bronchiolitis. We surveyed Colorado and Utah (where home O2 use is prevalent) chapter members of the American Academy of Pediatrics regarding bronchiolitis home O2 management. A total of 1030 providers were surveyed. The response rate was 21% (n = 214). Ninety percent of practicing primary care providers reported experience with home O2. Of those, 46% see patients on postdischarge day 1. Most providers see patients 1 to 3 times before stopping O2. Eighty percent continue O2 for 3 to 7 days. Weaning procedures vary and 56% practice more than 1 method. Most (41%) do not use continuous pulse oximetry. Challenges include parental noncompliance (51%) and difficulty knowing when to stop the O2 (57%). Management of home O2 in patients with bronchiolitis is a common in UT and CO. Weaning practices vary. Further research is needed.

Efectividad de la electrocardiografía fetal frente a la pulsioximetría para la determinación del bienestar fetal

Labor poses a potential risk for fetal well-being. New methods have been developed of continuous fetal pulse oximetry and fetal electrocardiogram analysis (STAN®). Our aim was to compare clinical outcomes after the STAN® system or pulse oximetry to determine fetal well-being during labor. We carried out specific searches in the major databases and applied predefined inclusion and exclusion criteria. Two prospective studies and a systematic review were selected.The instrumental delivery rate was higher with STAN® than with pulse oximetry. Metabolic acidosis rates, neonatal encephalopathy rates, and the number of pH determinations were lower when STAN® was used in combination with cardiotocography than when cardiotocography was used alone.

Capnography during deep sedation with propofol by nonanesthesiologists: a randomized controlled trial.

Propofol, a short-acting hypnotic drug, is increasingly administered by a diverse group of specialists (e.g., cardiologists, gastroenterologists) during diagnostic and therapeutic procedures. Standard monitoring during sedation comprises continuous pulse oximetry with visual assessment of the patient's breathing pattern. Because undetected hypoventilation is a common pathway for complications, capnographic monitoring of exhaled carbon dioxide has been advocated. We examined whether the use of capnography reduces the incidence of hypoxemia during nonanesthesiologist-administered propofol sedation in patients who did not receive supplemental oxygen routinely. An open, stratified, randomized controlled trial was conducted in 427 healthy adult women during minor gynecology procedures in an outpatient clinic in the Netherlands. Patients were randomly assigned to receive either standard respiratory monitoring (standard care) or standard respiratory monitoring combined with capnography (capnography group). To replicate usual clinical practice, capnography monitoring was performed by the same medical team that provided sedation. The primary end point was the incidence of hypoxemia, defined as oxygen saturations <91%. From April 2010 to January 2011, 427 patients were enrolled. In the capnography group, 206 patients and in the standard care group, 209 patients were analyzed. The percentage of patients with a hypoxemic episode was 25.7% (53 of 206) in the capnography group and 24.9% (52 of 209) in the standard care group, resulting in an absolute difference of 0.8% (-7.5 to 9.2%). We were unable to confirm an additive role for capnography in preventing hypoxemia during elective nonanesthesiologist-administered propofol (monotherapy) sedation in healthy women in whom supplemental oxygen is not routinely administered. Based on the confidence interval, the benefit of adding capnography is at most an absolute hypoxemia reduction of 7.5%, suggesting that adding it in this practice setting to the routine monitoring strategy does not necessarily improve patient safety in daily practice.

P711 A NOVEL GENETIC MAKER TO IMPROVE THE PREDICTION OF HCV SPONTANEOUS CLEARANCE: POLYMORPHISMS CONSISTING OF (TA)N DINUCLEOTIDE REPEAT NEAR IL28B GENE

irreversible CYP3A4 inhibitor, and inhibitor of multiple cellular uptake and efflux transporters. This study evaluated the interaction between ALV and methadone to assess potential clinical risks for methadone withdrawal or toxicity. Methods: Open-label screening (Part 1) and randomized, placebocontrolled, double blind (Part 2) investigation. Healthy subjects received a single 5mg dose of methadone before and after ALV (Part 1). Then, opioid-dependent patients on stable MMT (≤150mg daily) were randomized (2:1) to receive ALV 600mg BID or placebo for 7 days (Part 2). Safety assessments included daily vitals and 12lead ECGs, laboratory tests, and continuous pulse oximetry. Blood samples were collected for Rand S-methadone concentrations prior to and after dose administration on D1 (before ALV) and D8. Non-compartmental PK analysis was performed. Results: 16 healthy and 22 MMT subjects (14 active; 8 placebo) were enrolled. Two healthy and 2 MMT subjects withdrew consent before study completion. Dizziness (37.5%), headache (18.8%), and nausea (18.8%) were the most commonly reported AEs among healthy subjects; somnolence (30.8% vs. 25.0%), headache (30.8% vs. 12.5%), nausea (15.4% vs. 0%), and tremor (15.4% vs. 0%) among MMT subjects receiving ALV vs. placebo.

Pulse oximetry for perioperative monitoring

This is an update of a review last published in Issue 9, 2009, of The Cochrane Library. Pulse oximetry is used extensively in the perioperative period and might improve patient outcomes by enabling early diagnosis and, consequently, correction of perioperative events that might cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry during anaesthesia and in the recovery room have been performed that describe perioperative hypoxaemic events, postoperative cardiopulmonary complications and cognitive dysfunction. To study the use of perioperative monitoring with pulse oximetry to clearly identify adverse outcomes that might be prevented or improved by its use.The following hypotheses were tested.1. Use of pulse oximetry is associated with improvement in the detection and treatment of hypoxaemia.2. Early detection and treatment of hypoxaemia reduce morbidity and mortality in the perioperative period.3. Use of pulse oximetry per se reduces morbidity and mortality in the perioperative period.4. Use of pulse oximetry reduces unplanned respiratory admissions to the intensive care unit (ICU), decreases the length of ICU readmission or both. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 5), MEDLINE (1966 to June 2013), EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), ISI Web of Science (1956 to June 2013), LILACS (1982 to June 2013) and databases of ongoing trials; we also checked the reference lists of trials and review articles. The original search was performed in January 2005, and a previous update was performed in May 2009. We included all controlled trials that randomly assigned participants to pulse oximetry or no pulse oximetry during the perioperative period. Two review authors independently assessed data in relation to events detectable by pulse oximetry, any serious complications that occurred during anaesthesia or in the postoperative period and intraoperative or postoperative mortality. The last update of the review identified five eligible studies. The updated search found one study that is awaiting assessment but no additional eligible studies. We considered studies with data from a total of 22,992 participants that were eligible for analysis. These studies gave insufficient detail on the methods used for randomization and allocation concealment. It was impossible for study personnel to be blinded to participant allocation in the study, as they needed to be able to respond to oximetry readings. Appropriate steps were taken to minimize detection bias for hypoxaemia and complication outcomes. Results indicated that hypoxaemia was reduced in the pulse oximetry group, both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5 to three times less. Postoperative cognitive function was independent of perioperative monitoring with pulse oximetry. A single study in general surgery showed that postoperative complications occurred in 10% of participants in the oximetry group and in 9.4% of those in the control group. No statistically significant differences in cardiovascular, respiratory, neurological or infectious complications were detected in the two groups. The duration of hospital stay was a median of five days in both groups, and equal numbers of in-hospital deaths were reported in the two groups. Continuous pulse oximetry has the potential to increase vigilance and decrease pulmonary complications after cardiothoracic surgery; however, routine continuous monitoring did not reduce transfer to an ICU and did not decrease overall mortality. These studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we found no evidence that pulse oximetry affects the outcome of anaesthesia for patients. The conflicting subjective and objective study results, despite an intense methodical collection of data from a relatively large general surgery population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency. Routine continuous pulse oximetry monitoring did not reduce transfer to the ICU and did not decrease mortality, and it is unclear whether any real benefit was derived from the application of this technology for patients recovering from cardiothoracic surgery in a general care area.

Ventilación mecánica no invasiva. Reflexiones sobre la monitorización a domicilio

CIBERES, Ciber de enfermedades respiratorias, Spain Home-based noninvasive ventilation (NIV) was initiated in the early nineties in our environment as a treatment for patients with chronic respiratory failure, secondary to restrictive ventilatory disorders or neuromuscular disease. Subsequently, NIV also proved effective in patients with obesity-related hypoventilation syndromes, and to a lesser extent in some patients with chronic obstructive pulmonary disease in stable phase. There was a simultaneous growth in interest in whether the selected parameters suited the patients’ needs when using NIV in the home setting. Thus, the use of continuous overnight pulse oximetry monitoring as the gold standard for home monitoring in centers prescribing ventilation became widespread. The main issue with pulse oximetry has undoubtedly been its lack of specificity for correlation with certain patterns of patient–ventilator interaction. In other words, the effects of adverse events (desaturation) were detected, but there was a limited understanding of the underlying causes, and therefore of the potential solutions. In order to improve the performance of pulse oximetry, a series of simplified polygraphic systems have appeared in recent years, mostly in association with the ventilator manufacturers. These systems provide a set of data on the patient’s respiratory mechanics that can be downloaded from the ventilator’s internal memory. The main purpose is to provide the clinician with additional information on the potential reasons for inadequate ventilation periods and the pathophysiological causes (unintentional interface leaks, uncorrected upper airway episodes, asynchrony, etc.). Over the years, almost all manufacturers of ventilation systems have developed their own download system and data display. 1 However, in our view, the performance and reliability of these devices, which are widely used today, should be analyzed in depth. The first premise to be considered by the clinician is that a number of values provided by these software systems are not measured directly. In single-tube systems, the most widely used in home

Robotic Anesthesia: How is it Going to Change Our Practice?

Robotic Anesthesia: How is it Going to Change Our Practice?

Intubation in the delivery room: Experience with nasal midazolam

BackgroundNeonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AimsTo assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. Study designProspective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SubjectsTwenty-seven neonates with median (Q25–75) gestational age and birthweight of, respectively, 29 (27–33)weeks and 1270 (817–1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. Outcome measuresComfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. ResultsSeventy percent of the patients required a single dose, with intubation performed 4.8 (3–9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34–44)mmHg before to 31 (25–33)mmHg 1h following nMDZ (p=0.011). ConclusionnMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.

Abstract 209: Focused Training Results in a Decrease in Inpatient Respiratory Arrests

Background: The leading cause of inpatient arrests are due to respiratory causes and in our hospital, due to apneic/hypopneic events. Objective: To characterize patterns of apneic and hypopneic events in at risk population. Methods: This study was performed in one urban, academic inpatient facility. Eighteen at risk postoperative patients were identified in the post-anesthesia care unit (PACU) and admitted to the intermediate care unit (IMU) with continuous pulse oximetry and capnometry. Criteria included apnea, hypopnea, bradypnea (less than 8 breaths per minute), and inability to wean of nasal cannula oxygen. Major and minor events were identified (Fig. 1). Results: Patients who exhibited major apneic events had a significantly greater number of minor apneic events per shift relative to those who only had minor events (8.3 vs 2.5, Fig. 2). The day shift (8am-8pm) had more major apneic events (83.4% vs 16.6, Fig. 3) than the evening shift (8pm-8am). Incidentally, the training for this trial effectively reduced the number of total respiratory arrests in the hospital (Fig. 4).

Anesthesia and the Lone Star State

The field of anesthesiology has changed dramatically from its humble beginnings. Rags of ether and the art of monitoring blood color for oxygenation have been replaced with precise concentrations of inhaled anesthetic and continuous pulse oximetry. It is on the shoulders of our predecessors that we stand today as anesthesiologists. We must constantly evolve to adapt to an ever-changing medical profession. It is this spirit and mind-set that will allow the field of anesthesiology to continue to advance and improve the care of our patients.

Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value

Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results. A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Tu1259 Perioperative Predictors of Respiratory Compromise in Morbidly Obese Patients Undergoing Upper Endoscopy

The morbidly obese patient undergoing sedation has a known increased respiratory risk secondary to sedation and underlying decreased pulmonary reserve. Advanced monitoring (capnography) was added to routine monitoring (continuous pulse oximetry, heart rate and blood pressure) to determine cardiovascular changes. The aim of this prospective study was to determine which factors predict morbidity in this population undergoing upper endoscopy.

ASPMN Survey—Nurses' Practice Patterns Related to Monitoring and Preventing Respiratory Depression

The American Society for Pain Management Nursing convened a taskforce to develop guidelines on monitoring for opioid-induced sedation and respiratory depression. Part of the guideline development was the determination of nursing practice patterns related to monitoring and preventing respiratory depression during the administration of analgesics for pain. One hundred and forty-seven responses were received from 90 unique institutions across the United States. Monitoring adults with intermittent pulse oximetry while using intravenous patient-controlled analgesia (IV PCA) was 58%. Adults were monitored with continuous pulse oximetry by 25% of respondents. When using continuous epidural analgesia, 56% of patients were monitored intermittently, and 40% were monitored continuously. The use of end tidal CO2 (ETCO2) monitoring was much less, with 2.2% patients on epidural therapy, and 1.5% of institutions were using ETCO2 with IV PCA. The survey also included the location of the alarm, respiratory parameters for alarms, changes in procedures reported by institutions, and definitions of high-risk patients.