In these days of consciousness monitors, pulse oximeters, capnography and a host of other modern monitoring options, how do you know if you're monitoring all of your surgical patients effectively? Are you over-relying on your machines at the expense of clinical observation? Or are you foregoing a technology that could help ensure the safety of your patients? To get an idea of how practitioners are monitoring patients during anesthesia, we conducted a survey. Nearly 250 readers weighed in, and here's what they had to say.

Pre-procedure monitoring
Of the facilities that administer minimal IV sedation outside of the OR, about two-thirds (64 percent) routinely monitor these patients. For these readers, pre-procedure monitoring always includes oxygen saturation and nearly always includes vitals at routine intervals and direct clinical observation.

"All of our patients, regardless of how much IV sedation they receive, are placed on a pulse oximeter. In addition, the anesthesiologist notifies the pre-op holding nurse when a patient receives a sedative," says Donald Ganim II, MD, MSc, chief of anesthesia with the Beverly, Mass.-based Northeast Hospital System. "This way, we can keep a closer eye on these people."

One-third of those who perform routine pre-procedure monitoring for minimally sedated patients also perform routine ECG/EKG on them. "Pre-procedure assessment is essential, especially the baseline EKG," says Bunny Twiford, RN, director of clinical support with Physicians Endoscopy in Doylestown, Pa. "For some, this may be the first strip ever run on them. We need to know a starting point so we may evaluate any deviation that may occur once you introduce drugs into their system."

A Florida PACU nurse agrees: "How do you know what's normal for patients before anesthesia induction or sedation if they're not on a cardiac monitor in the pre-op area?"

Fourteen percent of panelists perform pre-procedure monitoring of minimally sedated patients at their discretion. For them, the following circumstances typically play a deciding role:

• level of sedation,
• adjunctive drugs,
• patient response to sedation,
• patient age,
• co-morbidities and
• length of pre-op stay.

"We place patients on a pulse oximeter if they're elderly; are at higher risk due to morbid obesity, cardiopulmonary disease or other conditions; receive a narcotic with an anxiolytic; or if we have a lower staff-to-patient ratio than usual," says one panelist.

For a hospital-based OR nurse, staffing plays too big of a role in the decision to monitor minimally sedated patients: "Our holding area is staffed by pre-op (admitting) RNs. Their primary concern is the paperwork required to get the patient ready for surgery. If they remember or are reminded, they attach the monitoring devices, but this doesn't mean they actively monitor the patient."

Whether your monitoring of these patients is routine or conditional, some patients can benefit from the increased care, especially those with health complications, says Alan P. Marco, MD, MMM, professor and chairman of the Medical University of Ohio in Toledo.

Intra-op monitoring
Intraoperatively, our panelists monitor vitals, oxygen saturation and ECG/EKG while observing respiration regardless of the level or type of anesthesia. Temperature and quantitative CO2 (capnography, for example), however, are routine only during general anesthesia. During IV sedation, 40 percent perform routine temperature checks and 40 percent perform quantitative CO2. Several panelists expressed concern about the latter.

"I'd like to see CO2 monitoring used on MAC or IV sedation cases, as the CO2 wave form changes well in advance of a drop in patient SaO2," says Larry A. Snyder, CRNA, anesthesia manager with St. Vincent Memorial Hospital in Taylorville, Ill.

Adds a staff nurse: "We do an excellent job of monitoring, but we probably should be using end-tidal CO2 monitoring for conscious sedation."

Current American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring don't require this, but they do suggest it. Specifically, the standards recommend monitoring ventilation via "continual observation of qualitative clinical signs and/or monitoring for the presence of exhaled carbon dioxide" during regional anesthesia and monitored anesthesia care. The standards specifically recommend quantitative end-tidal CO2 whenever the patient receives an endotracheal tube or laryngeal mask.

About two-thirds of facilities that perform general anesthesia also monitor the end-tidal concentration of volatile anesthetics routinely. The remainder do so as circumstances necessitate it. The advantage of this information, say these panelists, is that it can help ensure a successful flush of the respiratory circuit at the end of the case.

"Our monitors automatically monitor end-tidal inhalational agents and nitrous oxide. This helps with emergence, as we trend down the sevoflurane and flush the circuit. The end-tidal monitor confirms that we successfully flushed the inspiratory limb, speeding emergence," says Ray Hasel, MD, FRCPC, CSPQ, DABA, anesthesiologist with L'Ouest de L'Isle in Pointe Claire, Quebec. Shirley Ramey, RN, nurse-manager with the ASC of Burley, in Burley, Idaho, notes that this information becomes especially useful when the patient is slow to awaken.

Among our panelists, routine consciousness monitoring is a relative rarity. Sixty percent report that they never use technologies like BIS, in part because some never or rarely use general anesthesia. Just 13 percent perform consciousness monitoring routinely, and an additional 22 percent use it selectively. In this latter group, usage depends on practitioner preference, and many reserve it for patients with a history or risk of anesthesia awareness who undergo general anesthesia. Other deciding factors include age (elderly patients, for example), type of case (such as cardiac or trauma) and conditions (like neurological impairment or blood pressure problems) that inhibit achievement of sufficient end-tidal anesthetic gas concentrations. One dedicated user, a staff CRNA, says: "It is an end-organ measure of anesthetic effect. It optimizes patient care. We monitor every other end organ we impact; why not monitor the brain?"

No better monitor
Many of our panelists express concern that the growing number of monitors and technologies, along with the emphasis on standards and protocols, is placing machines above man. That is, they say, over-reliance on readouts at the expense of clinical observation and judgment can compromise patient care.

"Clinical signs are much more valuable than a digital readout of exhaled anesthetic agents, but not as easily quantified to the satisfaction of non-anesthesia providers such as risk managers, lawyers and the spectrum of anesthetists who are not as attuned to monitoring patients as they are to watching monitors," says CRNA James Mellema with the Sitka, Alaska-based Mt. Edgecumbe Hospital. "It's a pity that looking at patients has become the exception rather than the norm for anesthesia providers."

Kenneth Lewis, MD, chairman of the department of anesthesiology at King/Drew Medical Center in Los Angeles, agrees that some give monitors too much credence. "Is there still a place for the precordial stethoscope, or has capnography replaced this very basic and inexpensive piece of equipment?," he asks. Adds Thomas L. Cravens, a CRNA with the Gerald Champion Regional Medical Center in Alamogordo, N.M.: "BIS correlates with potential recall. It doesn't prevent recall, and if an anesthetic provider is vigilant and conscientious, there are more data to be gained from paying attention to the patient than another monitor."

Finding the right balance, says a director of anesthesia with a plastic surgery center, takes vigilance. It also takes familiarity and comfort with the setting.

"I often find that hospital-based anesthesiologists who cover for me aren't accustomed to the office setting and expect the same level of monitoring on all patients even when the type of anesthesia used (topical with minimal sedation or IV anesthesia with spontaneous respirations, for example) doesn't really require it," he says. "You can provide the same quality of care with common sense and vigilance. When I trained, we didn't have all these fancy monitors. We had to watch our patients."