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Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis

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Abstract

End-tidal CO2 has been advocated to improve safety of emergency department (ED) procedural sedation by decreasing hypoxia and catastrophic outcomes. This study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO2 monitoring for ED procedural sedation in prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Estimates for efficacy of capnography and safety of sedation were derived from the literature. This model was then applied to all procedural sedations performed in US EDs with assumptions selected to maximize efficacy and minimize cost of implementation. Assuming that capnography decreases the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per 5 years). Over a 5-year period, implementing routine end-tidal CO2 monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted life-year. Sensitivity analyses suggest that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO2 monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.

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Acknowledgements

The authors would like to acknowledge the assistance of Tim Orris for his assistance in estimating costs of capnography equipment, Kari Harland, PhD, MPH for her assistance with analysis of NEDS data, and Mindi Allbaugh for her assistance in literature review. This study was funded by the University of Iowa Department of Emergency Medicine.

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Authors and Affiliations

  1. Department of Emergency Medicine, University of Iowa College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA

    Nicholas Matthew Mohr, Andrew Stoltze & Azeemuddin Ahmed

  2. Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA

    Nicholas Matthew Mohr

  3. Hardin Library for the Health Sciences, University of Iowa, 600 Newton Road, Iowa City, IA, 52242, USA

    Elizabeth Kiscaden

  4. Department of Health Management and Policy, University of Iowa College of Public Health, 145 N. Riverside Drive, Iowa City, IA, 52246, USA

    Dan Shane

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Correspondence to Nicholas Matthew Mohr.

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The authors have no relevant conflicts of interest to declare in relation to this work, and neither the authors nor their institution received any funding to conduct this study.

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All procedures performed were in accordance with ethical standards of the 1964 Helsinki declaration and its later amendments. This study was determined not to qualify as human subjects research by the local IRB.

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This study did not involve human subjects, and thus did not require informed consent.

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Mohr, N.M., Stoltze, A., Ahmed, A. et al. Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis. Intern Emerg Med 13, 75–85 (2018). https://doi.org/10.1007/s11739-016-1587-3

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