By Rose Dodson, M.S., CEO; Sedation Resource, Inc.What makes a device a monitor? What meets state requirements and my practice needs?
While it’s generally considered a safe practice, there’s a level of mortality accompanying sedation. The standards of monitoring continue to be advanced by professional organizations with the objective of improving care.
Texas regulations on sedating a patient1 include monitoring the level of consciousness, oxygenation, ventilation, and circulation; and documentation—a written, time-oriented record of a patient’s various vital signs.
In order to determine the type of monitor needed for the sedation provided at your practice, you need to understand what makes a device a monitor and meets state requirements. Of course, you also want the monitor to meet the preferences of your practice.
Monitoring
To be clear, the best monitor can’t be purchased and is not a device; it’s the practitioner. It’s important to never lose a sense of awareness and to always pay attention to the patient. In fact, over 50% of each area to be monitored requires the practitioner’s senses.
Level of Consciousness
Practitioners use their senses to monitor consciousness. It involves simply checking for responsiveness to verbal commands. For example, asking the patient, “Hey, Susie, how are you feeling?” would prompt a patient to respond. A patient is obviously conscious if they can respond to anything asked of them.
Oxygenation
Here again, practitioners use their senses to look at the color of mucosa and skin to ascertain a certain level of oxygenation. However, a pulse oximeter—a device that measures oxygen saturation in a patient—can also be used.
Ventilation
A patient’s breathing can be assessed either through observing chest movements or verbal communication. It can also be assessed through listening to breath sounds, which can often be heard by the practitioner placing their ears downwards toward the patient’s mouth or nose. However, a pre-tracheal stethoscope can be used to listen more efficiently. Additionally, ventilation can be determined through use of a capnograph—also known as a CO2 monitor—which measures the level of CO2 a patient breathes out.
Circulation
Measuring blood flow or cardiac output is done by taking a patient’s blood pressure, measuring heart rate, and/or by utilizing an electrocardiograph.
What makes a device a monitor?
By definition, a monitor is used for observing, checking, or keeping a continuous record of something. As a verb, it is “to watch, check or observe for a special purpose,” but specifically to “warn.” A monitor is actually a device intended to warn a practitioner of an ongoing issue.
Diagnostic devices, such as a finger pulse oximeter, a blood pressure measuring device, and a thermometer can typically be found at a dental office. Why couldn’t the finger pulse oximeter be simply used every 10 minutes and a reading recorded?
Here are the features that make a simple device a monitor:
Audible and visual alarms.
Tones and alarms are an absolute must for a device to be an actual monitor. It eliminates the need for the practitioner and/or staff to continually stare at that pulse oximeter and gives a warning if the reading drops below an acceptable level. During a busy sedation case, a drop in the pulse oximeter tone is an important indicator to bring attention to a potential physiological change.
Automatic blood pressure monitor.
An automatic blood pressure device can be set to a specific interval and inflates on its own to record a patient’s blood pressure at the given interval. There are semi-automatic blood pressure diagnostic devices that necessitate pressing a button every time the blood pressure is to be taken. However, beside the fact they don’t have alarms, they leave room for delayed readings or forgetting to press the button and missing a reading altogether.
Respiration rate.
Respiration is the one baseline vital sign that is not a standard on a basic monitor. Perhaps this is one of the reasons it’s termed the forgotten vital sign.
What are your options for obtaining a respiration rate on a monitor? Typically, respiration rate on a monitor is obtained by electrocardiogram (ECG). It works by measuring the thoracic impedance across the ribs, measuring the rise and fall of the chest to calculate the respiration rate. This works best in patients who are still and comfortably sedated. Patient movement and incorrect placement of ECG pads often result in excessive false alarms.
Another way respiration rate is determined through a monitor is by utilizing capnography. As the monitor is measuring the level of end-tidal CO2 , respiration rate is also determined. This reading is often differentiated with a term such as awRR (airway respiration rate) or BRm (breath rate per minute).
Documentation
The patient’s measured vitals must be documented. At all levels of sedation, including nitrous, baseline vital signs must be recorded in accordance with Texas State Board of Dental Examiners Rules 108.7 and 108.8. This is repeated at every level of sedation. Everyone must record baseline vital signs. These include:
- Pulse oximetry
- Heart rate
- Respiratory rate
- Blood pressure
While all levels of sedation need baseline vital signs recorded, there are a few variances for the subsequent time-oriented documentation. For example, SpO2 (oxygen saturation) must be used for level 1 sedation only if nitrous is added to a single drug sedative. In terms of the time-oriented record though, records may be documented every 10 minutes, according to the regulations.
For levels 2 (oral sedation) and 3 (IV sedation), it is very plain: records must be documented every 10 minutes. These include pulse ox, heart rate, respiratory rate, and blood pressure. For Level 4 (deep sedation), records must be documented every five minutes.
To fulfill the requirement of having a time-oriented record of sedation, many prefer to have a printer on their monitor. The bottom line is that once the anesthesia or sedation case is complete, the record needs to show values for all the vitals that were monitored.
A Monitor to Check All the Boxes
Looking for a monitor that meets the requirements for your level of sedation permit would be a great starting point.
At a minimum, most basic vital signs monitors have a pulse oximeter to determine oxygenation. Additionally, they include non-invasive automatic blood pressure monitoring and will give the heart rate, which will check the circulation box. It should be noted, however, that for level 3 and 4, an ECG is required.
Two things that are closely related are ventilation and respiration. How will ventilation be monitored? And how will respiration rate be measured and documented?
If the preference is to have respiration rate recorded on the monitor, then a full-parameter monitor that includes ETCO2 may be the ticket—even for a level 2 or 3 sedation provider. Capnography is required for a level 4 sedation permit holder. Capnography measures ventilation and will also give you a respiration reading for your documentation.
As mentioned, ventilation can also be measured by auscultation of breath sounds with a pre-tracheal stethoscope. Since this is a very accurate and effective way to measure ventilation, it’s often utilized, even though it’s not required. When using a pre-tracheal stethoscope, respiration rate will need to be calculated and documented manually.
What about level of consciousness? While there’s a monitoring component called EEG or electroencephalogram that measures level of consciousness, it’s not considered necessary for conscious sedation. Thus, responsiveness to verbal command is deemed to be adequate for all levels of conscious sedation.
Conclusion
Choosing a monitor to meet sedation regulations may seem like a daunting task, however the ultimate goal is increased patient safety. A monitor that meets the regulations and works well with the practice needs will make sedation simple, safe, and effective.
1Texas Rules and Regulations Administrative Code Title 22 Part 5 Chapter 110