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## Complete Summary

#### GUIDELINE TITLE

Transcutaneous blood gas monitoring for neonatal & pediatric patients
--- 2004 revision & update.

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care. Transcutaneous blood gas
monitoring for neonatal & pediatric patients\--2004 revision & update.
Respir Care 2004 Sep;49(9):1069-72. \[38 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline.
Transcutaneous blood gas monitoring for neonatal & pediatric patients.
Respir Care 1994 Dec;39(12):1176-9.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pulmonary disease

#### GUIDELINE CATEGORY

Risk Assessment

#### CLINICAL SPECIALTY

Pediatrics\
Pulmonary Medicine

#### INTENDED USERS

Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

-   To improve the consistency and appropriateness of respiratory care
    and serve as a guide for education and research

-   To provide clinical practice guidelines on transcutaneous monitoring
    of oxygen (P~tcO2~) and carbon dioxide (P~tcCO2~) in neonates,
    infants, and small children

#### TARGET POPULATION

Neonates, infants, and small children who need to be monitored to assess
the adequacy of arterial oxygenation and/or ventilation, or who need to
have the response to diagnostic and therapeutic interventions
quantitated as evidenced by transcutaneous monitoring of oxygen
(P~tcO2~) and/or transcutaneous monitoring of carbon dioxide (P~tcCO2~)
values.

**Note**: This guideline does not address the application of
transcutaneous monitoring in adults and older children.

#### INTERVENTIONS AND PRACTICES CONSIDERED

Transcutaneous blood gas monitoring

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Consultants to the Working Group may review the initial draft of the
guideline. After completion by the Working Group, the draft is reviewed
by the entire Steering Committee and then by a Review Panel (i.e.,
persons engaged in all facets of the delivery of respiratory care who
have volunteered to review drafts of the Guidelines before publication).

The 2004 update was approved by the 2003 Clinical Practice Guideline
(CPG) Steering Committee.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Procedure**

Transcutaneous monitoring of oxygen (P~tcO2~) and carbon dioxide
(P~tcCO2~) in neonates, infants, and small children-this guideline does
not address the application of transcutaneous monitoring in adults and
older children.

**Description/Definition**

Transcutaneous monitoring measures skin-surface P~O2~ and P~CO2~ to
provide estimates of arterial partial pressure of oxygen and carbon
dioxide (P~aO2~ and P~aCO2~). The devices induce hyperperfusion by local
heating of the skin and measure the partial pressure of oxygen and
carbon dioxide electrochemically.

**Setting**

Transcutaneous monitoring may be performed by trained personnel in a
variety of settings including (but not limited to) hospitals, extended
care facilities, and patient transport.

**Indications**

-   The need to monitor the adequacy of arterial oxygenation and/or
    ventilation

-   The need to quantitate the response to diagnostic and therapeutic
    interventions as evidenced by P~tcO2~ and/or P~tcCO2~ values

**Contraindications**

Refer to the \"Contraindications\" field or see the original guideline
document for information.

**Hazards/Complications**

Refer to the \"Potential Harms\" field or see the original guideline
document for information.

**Device Limitations/Validation of Results**

P~tcO2~ is an indirect measurement of P~aO2~ and, like P~aO2~, does not
reflect oxygen delivery or oxygen content. Complete assessment of oxygen
delivery requires knowledge of hemoglobin, saturation, and cardiac
output. In a similar way, P~tcCO2~ is an indirect measurement of P~aCO2~
but knowledge of delivery and content is not necessary to use P~tcCO2~
as an indicator of adequacy of ventilation.

-   Factors, agents, or situations that may affect readings, limit
    precision, or limit the performance or application of a
    transcutaneous monitor include

    -   Technical

        -   The procedure may be labor intensive, although newer designs
            make application quicker and simpler.

        -   Prolonged stabilization time is required following electrode
            placement.

        -   Manufacturers state that electrodes must be heated to
            produce valid results; however, clinical studies suggest
            that valid results may be obtained with P~tcCO2~ electrodes
            operated at lower than recommended temperatures or with no
            heat.

        -   The theoretical basis for mandatory heating of the P~tcO2~
            electrode is established.

        -   Improper calibration, trapped air bubbles, damaged membranes
            are possible and may be difficult to detect.

    -   Clinical: The following factors may increase the discrepancy
        between arterial and transcutaneous values:

        -   The presence of hyperoxemia (P~aO2~ \>100 torr)

        -   The presence of a hypoperfused state (shock, acidosis)

        -   Improper electrode placement or application

        -   Vasoactive drugs

        -   The nature of the patient\'s skin and subcutaneous tissue
            (skinfold thickness, edema)

-   Validation: Arterial blood gas values should be compared to
    transcutaneous readings taken at the time of arterial sampling in
    order to validate the transcutaneous values. This validation should
    be performed initially and periodically as dictated by the
    patient\'s clinical state.

    -   During validation studies in patients with functional shunts,
        electrode site and arterial sampling site should be on the same
        side of the shunt.

    -   When disparity exists between transcutaneous and arterial values
        and the clinical presentation of the patient, possible causes
        should be explored before results are reported. Monitoring at
        alternate sites, recalibration, or appropriate substitution of
        instruments may reduce discrepancies. If such steps do not
        remedy the disparity, transcutaneous results should not be
        reported; instead a statement describing the corrective action
        should be included in the patient\'s chart and some other mode
        of monitoring should be established (e.g., pulse oximetry and/or
        arterial blood analysis). The absolute limits that constitute
        unacceptable disparity vary with patient condition and specific
        device. Clinical judgment must be exercised.

-   To help assure consistency of care based on transcutaneous blood gas
    readings, the operator should verify that:

    -   High- and low-limit alarms are set appropriately

    -   Appropriate electrode temperature is set

    -   Electrode placement is appropriate and systematic electrode-site
        change occurs

    -   Specific manufacturer\'s recommendations for maintenance,
        operation, and safety are complied with

**Assessment of Need**

-   When direct measurement of arterial blood is not available or
    accessible in a timely fashion, P~tcO2~ and/or P~tcCO2~ measurements
    may temporarily suffice if the limitations of the data are
    appreciated.

-   Transcutaneous blood gas monitoring is appropriate for continuous
    and prolonged monitoring (e.g., during mechanical ventilation,
    continuous positive airway pressure \[CPAP\], and supplemental
    oxygen administration).

-   P~tcO2~ values can be used for diagnostic purposes as in the
    assessment of functional shunts (e.g., persistent pulmonary
    hypertension of the newborn \[PPHN\] or persistent fetal
    circulation) or to determine the response to oxygen challenge in the
    assessment of congenital heart disease.

**Assessment of Outcome**

-   Results should reflect the patient\'s clinical condition (i.e.,
    validate the basis for ordering the monitoring).

-   Documentation of results, therapeutic intervention (or lack of),
    and/or clinical decisions based on the transcutaneous measurements
    should be noted in the medical record.

**Resources**

-   Equipment: Transcutaneous monitor, electrodes, calibration gases,
    and associated expendable supplies-the monitor should have been
    validated by the manufacturer, using appropriate quality control
    procedures and clinical reliability studies.

-   Personnel: Licensed or credentialed respiratory care practitioners
    or other credentialed persons with equivalent training and
    demonstrated ability to exercise the necessary clinical judgment,
    assess the patient, and perform the essential tasks of calibration
    and application.

**Monitoring**:

The monitoring schedule of patient and equipment during transcutaneous
monitoring should be integrated into patient assessment and vital signs
determinations. Results should be documented in the patient\'s medical
record and should detail the conditions under which the readings were
obtained:

-   The date and time of measurement, transcutaneous reading, patient\'s
    position, respiratory rate, and activity level

-   Inspired oxygen concentration or supplemental oxygen flow,
    specifying the type of oxygen delivery device

-   Mode of ventilatory support, ventilator, or CPAP settings

-   Electrode placement site, electrode temperature, and time of
    placement

-   Results of simultaneously obtained P~aO2~, P~aCO2~, and pH when
    available

-   Clinical appearance of patient, subjective assessment of perfusion,
    pallor, and skin temperature

**Frequency**

Transcutaneous blood gas monitoring should be continuous for development
of trending data. So-called spot checks are not appropriate.

**Infection Control**

No special precautions are necessary, but Standard Precautions (as
described by the Centers for Disease Control and Prevention) are
recommended.

-   The device probe should be cleaned between patient applications
    according to manufacturer recommendations.

-   The external portion of the monitor should be cleaned according to
    manufacturer\'s recommendations whenever the device remains in a
    patient\'s room for prolonged periods, when soiled, or when it has
    come in contact with potentially transmissible organisms.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Effective monitoring of arterial partial pressure of oxygen and carbon
dioxide

#### POTENTIAL HARMS

P~tcO2~ and/or P~tcCO2~ monitoring is considered a safe procedure, but
because of device limitations, false-negative and false-positive results
may lead to inappropriate treatment of the patient. In addition, tissue
injury may occur at the measuring site (e.g., erythema, blisters, burns,
skin tears).

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

In patients with poor skin integrity and/or adhesive allergy,
transcutaneous monitoring may be relatively contraindicated.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care. Transcutaneous blood gas
monitoring for neonatal & pediatric patients\--2004 revision & update.
Respir Care 2004 Sep;49(9):1069-72. \[38 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1994 Dec (revised 2004 Sep)

#### GUIDELINE DEVELOPER(S)

American Association for Respiratory Care - Professional Association

#### SOURCE(S) OF FUNDING

American Association for Respiratory Care (AARC)

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Steven E Sittig, RRT-NPS, Mayo Clinic, Rochester,
Minnesota

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline.
Transcutaneous blood gas monitoring for neonatal & pediatric patients.
Respir Care 1994 Dec;39(12):1176-9.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Association for Respiratory Care (AARC) Web
site](http://www.rcjournal.com/contents/09.04/09.04.1069.pdf).

Print copies: Available from the American Association for Respiratory
Care (AARC), CPG Desk, 11030 Ables Ln, Dallas, TX 75229-4593; Web site:
[www.aarc.org](http://www.aarc.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on November 30, 1998. The information
was verified by the guideline developer on December 15, 1998. This NGC
summary was updated by ECRI on March 21, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008