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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN

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Louis V. -

Question regarding the article on CT with vs. without PO contrast for dx of Appendicitis:

The study seemed to have focus on the concordance rate of CT with IV vs. without PO contrast (CT to OR concordance). However, even though the concordance results were the same for the CT scans (90%), this does not show that the diagnostic accuracy is the same on both kinds of studies. I think a comparison of how many appendicitis were missed with eat type of scanning would be much more important for the ER docs in practice?
The question that really matters to me is..... If I don't use PO contrast will I miss an appendicitis? Does reducing the false +'s really matter at the expense of missing an Appy?
Am I right? or Am I missing something?


Adam O. -

Regarding Paper Chase #2.
I disagree with the reviewers conclusions that EtCO2 monitoring was not helpful.
1. This study was conducted on a different population than ED patients undergoing PS (majority were healthy fasted women).
2. The depth of sedation was not as deep as many of our patients (these patients were moderate to deep and our patients tend to hover between deep and GA)
3. Minimally trained practitioners were administering PS.

This study also demonstrated to me that
1. Patients undergoing Procedural Sedation (PS) should be on supplemental oxygen (approx 25% rate of hypoxia and approx 3% rate of sats <81!). If this happened in my hospital PS would be banned. The argument that supplemental O2 obscured the additive value of sat monitoring is old and tired. Surely its better to prevent hypoxia than some notion of purity of monitoring.
2. capnographic changes preceded the onset of hypoxia two-thirds of the time. This seems to me to be an argument for the use of capnography. Advanced warning of 2/3 hypoxemic episodes is a powerful early warning (imagine a tool that predicts 2/3 of hypotension in PS patients).
3. The protocoled response to capnographic abnormalities in this study mandated responsive manoevers. In reality depending on multiple variables airway manipulation may not be required. This may explain the higher incidence of airway manipulation in the capnography group.
4. the ACEP Clinical Policy for PSA regarding the use of capnography provided a Level B grade recommendation (moderate clinical certainly) that capnogrpahy reduces the incidence of hypoxia and other study-defined respiratory events. There will never be a study that proves a reduction in serious adverse events because these are so exceptionally rare.

Overall this paper doe not convince me at all that capnography is not clinically useful. It does convince me that not using supplemental oxygen pre- and intra-PS is poor practice and that I would not recommend anyone I know having a procedure at the clinic where the study was conducted.

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