PURPOSE tcpco2 monitoring provides continuous non invasive monitoring of an infant s ventilatory status. The sensor consists of a Stow-Severinghaus-type electrode. The use of tcpco2 monitoring may facilitate less frequent blood gas analysis and more rapid weaning from mechanical ventilation. The tcpco2 can alert the clinician to changes in ventilatory status prior to the occurrence of other physiological changes. POLICY STATEMENTS The Registered Respiratory Therapist (RRT) will set up, monitor and discontinue continuous transcutaneous carbon dioxide (tcpco2) for infants who meet the criteria for continuous PCO2 monitoring. SITE APPLICABILITY tcpco2 monitoring occurs in the neonatal intensive care unit at BCWH on infants with unstable respiratory/ventilatory conditions. PRACTICE LEVEL/COMPETENCIES RRTs must be aware of the clinical limitations of this technology. They should understand the relationship between tcpco2 and PaCO2 and how the physiological relationship between cardiac output and ventilation can affect both of these values. Limitations to its clinical use include: 1. Peripheral vasoconstriction 2. Hypothermia 3. Skin anomalies 4. Skin edema Electrode measures the gas tension of the underlying tissue and not the arterial gas tension. Because metabolism of the tissue produces CO2 tcpco2 readings are usually higher than arterial values. DEFINITIONS & LIMITATIONS tcpco2 monitoring is intended only as an adjunct in patient assessment and must be used in conjunction with patient clinical signs and symptoms. tcpco2 monitoring is not used clinically on infants < 26 weeks corrected gestational age due to skin integrity for the first 3 days of life. tcpco2 monitoring is not used clinically on infants where poor skin integrity has been identified (if cardiac leads are not in use then tcpco2 monitoring is not supported) RRTs must be aware of the ideal patient application sites for optimal readings and correlation with arterial blood gas sampling. 1. Chest area avoiding nipples Page 1 of 6
2. Abdomen except in the presence of query or diagnosed Necrotizing Enterocolitis 3. Outer thighs 4. Lower back if patient is lying prone TCM4 has an internal memory and will maintain the previous parameters set by the clinician when turned off/on. TCM4 comes with an internal battery. When fully charged will last 1 hour. Monitor has no mechanism to warn the clinician when the battery is losing its charge. Monitor needs to be plugged into an electrical outlet when not in clinical use. Yellow light located above the power switch indicates that the internal battery is charging. EQUIPMENT 1. TCM4 monitor equipped with calibration cylinder, reusable cable & electrode (sensor) 2. Bottle of contact gel (grey bottle) comes in a box with the fixation rings 3. Fixation ring box of 60 4. 2x2 gauze 5. De-ionized water 6. Alcohol swabs TCM4 monitor is kept in the NICU RT room and needs to be plugged into an electrical outlet when not in clinical use. PROCEDURES Procedure 1. Collect supplies for set up & patient application Notes Ensure correct solution is collected. Contact solution is in the grey bottle. 2. Power on Located on bottom right hand corner 3. Calibration calibration required appears on screen SmartCal function is the default setting therefore calibration procedure is automatic and not initiated by the clinician. Ensures monitor is always ready for monitoring by calibrating the sensor when needed. Calibration automatically occurs every 6 hours Calibration is based upon Barometric Pressure and calibration gas percentage. 4. Ready Appears when calibration target has been reached. Monitor is ready for patient application. 5.Prior to Patient application Check temperature of sensor (default set at 42 degrees), To maintain good skin integrity: SmartHeat senor should always be Page 2 of 6
SmartHeat setting (OFF), Site time and Site time heat (OFF). To access sensor temperature, SmartHeat setting, Site time & Site time heat: Select Set up key (bottom right) Select Parameter Key (top left) Review all settings on screen Adjust settings as required: Using the blue arrow select desired parameter Using the appropriate black arrow adjust parameter Select OK to accept the changes and return to the main screen or select APPLY to remain on the current screen Site time should be set to 8 hours for all infants. Temperature should be set to 42 degrees for all infants. 7. Patient Preparation Choose site for fixation ring application Clean site with sterile water with a 2x2 gauze Dry Apply fixation ring run finger around circumference to ensure a good seal Allow 2 minutes to ensure proper adhesion to skin prior to connecting sensor. 8. Senor Application Apply 2 drops of contact gel to the center of the ring Remove senor from the calibration chamber located on the front of the monitor. OFF when ON it adds temperature to the set temperature, for several minutes, when the senor is removed from the calibration chamber. Leaving it off reduces the risk of skin injury. Site time heat is set to OFF sensor heat automatically turns itself off when the site time is reached therefore reducing the risk of skin injury. Skin integrity must be documented on the RT flowsheet with each site change. Chest area avoiding nipples Abdomen except in the presence of query or diagnosed Necrotizing Enterocolitis Outer thighs Lower back is lying supine Located on the monitor screen is a Data Line with proper sensor application this line will gradually cycle upward and plateau once the optimum CO2 has been achieved. Page 3 of 6
Gently press the senor against the skin until it snaps into place Twist sensor into position Do not place a piece of tape on top of the sensor to help with adhesion. 9. Setting Alarms To adjust alarms Select Set up key (bottom right) Select Parameter Key (top left) pco2 alarms are displayed Using the blue arrow select desired parameter Using the appropriate black arrow adjust parameter Select OK to accept the changes and return to the main screen or select APPLY to remain on the current screen 10. Event Marker To mark an event: Press event on the bottom of the screen Text will display Set event marker number x Press OK record event # for reference on the RT flowsheet and the significance of the event. The event number will be displayed on the top of screen correlating with the time of the event. To link the event to a patient; o Press ID located in the right upper corner o Select change ID o Using the top right hand arrow delete patient ID o Using the number pad input new ID o Confirm ID using the Stabilization of CO2 time is 5 10 minutes. In the event that the line does not plateau relocating the sensor is required. Under ideal conditions the correlation between tcpco2 and PaCO2 should be between 2 5 mmhg. Alarms should be set 10mmHg above and below the displayed value once optimum CO2 has been reached. Alerts the clinician that a change in the patient s respiratory status has occurred. Allows the clinician to objectively monitor a response to a change in a respiratory modality (ventilation parameter change, invasive to noninvasive ventilation, extubation etc.) Holds up to 99 events. Page 4 of 6
arrow located in the right bottom of screen. 11. Changing sensor sites Done every Q8H depending upon GA and hours of life. Leave existing fixation ring(s) on skin if already in place and rotate sensor between rings. 12. Calibration If clinician alters the temperature post calibration the senor will require recalibration. If calibration fails check for patency of the calibration gas holes located in calibration chamber. If noticeably plugged using a pin, gently unplug the hole(s). 13. Discontinuation Patient Remove sensor from fixation ring Monitor Power off (lower right bottom) Shut down appears on screen Touch OK Sensor Clean sensor with alcohol swab Provided the patient s skin is intact there is no need to change the sensor membrane between patients. Place sensor in calibration chamber located on the front of the monitor. Wipe monitor and sensor wire off with Cavi Wipes Wipe the screen off with a Cavi Wipe followed by water to clean off the chemical from the screen.. Place the monitor in the designated storage location. Minimize skin break down and possible skin burns. Minimize skin breakdown from removing and reapplying fixation rings to the skin. Wiping down the equipment and removing it from the patient bedside is good infection control practice. Not wiping the screen with water after using a Cavi Wipe will result in residual chemical being left on the screen over time chemicals can result in loss of sensitivity to the touch screen Plug monitor in to electrical Page 5 of 6
outlet Plugging the monitor into the electrical outlet ensures that the internal battery remains fully charged. DOCUMENTATION Frequency; With each site change Q3H as part of the invasive/noninvasive charting on the Respiratory Therapy Flowsheet. Charting includes: Initial application Site changes Event markings Calibration Ongoing continuous read out Any patient adverse events (skin break down, skin burns) REFERENCES 1. Perinatal and Pediatric Respiratory Care, Third Edition (2010), Brian Walsh, Michael Czervinske, Robert DiBlasi 2. Binder N etal, AMJ Perinatol 1994; 11: 237 Is a study of: use of a TC Sensor of 40 C was accurate in sample 644 pairs UAC vs. TcCO2. Page 6 of 6