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Coëffic A, Joachim J, Manquat E, Felliot É, Vallée F, Mebazaa A, Gayat É, Chousterman BG, Barthélémy R. Trending Ability of End-Tidal Capnography Monitoring During Mechanical Ventilation to Track Changes in Arterial Partial Pressure of Carbon Dioxide in Critically Ill Patients With Acute Brain Injury: A Monocenter Retrospective Study. Anesth Analg 2024; 138:607-615. [PMID: 37319022 DOI: 10.1213/ane.0000000000006553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Changes in arterial partial pressure of carbon dioxide (Pa co2 ) may alter cerebral perfusion in critically ill patients with acute brain injury. Consequently, international guidelines recommend normocapnia in mechanically ventilated patients with acute brain injury. The measurement of end-tidal capnography (Et co2 ) allows its approximation. Our objective was to report the agreement between trends in Et co2 and Pa co2 during mechanical ventilation in patients with acute brain injury. METHODS Retrospective monocenter study was conducted for 2 years. Critically ill patients with acute brain injury who required mechanical ventilation with continuous Et co2 monitoring and with 2 or more arterial gas were included. The agreement was evaluated according to the Bland and Altman analysis for repeated measurements with calculation of bias, and upper and lower limits of agreement. The directional concordance rate of changes between Et co2 and Pa co2 was evaluated with a 4-quadrant plot. A polar plot analysis was performed using the Critchley methods. RESULTS We analyzed the data of 255 patients with a total of 3923 paired ΔEt co2 and ΔPa co2 (9 values per patient in median). Mean bias by Bland and Altman analysis was -8.1 (95 CI, -7.9 to -8.3) mm Hg. The directional concordance rate between Et co2 and Pa co2 was 55.8%. The mean radial bias by polar plot analysis was -4.4° (95% CI, -5.5 to -3.3) with radial limit of agreement (LOA) of ±62.8° with radial LOA 95% CI of ±1.9°. CONCLUSIONS Our results question the performance of trending ability of Et co2 to track changes in Pa co2 in a population of critically ill patients with acute brain injury. Changes in Et co2 largely failed to follow changes in Pa co2 in both direction (ie, low concordance rate) and magnitude (ie, large radial LOA). These results need to be confirmed in prospective studies to minimize the risk of bias.
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Affiliation(s)
- Adrien Coëffic
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
| | - Jona Joachim
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- Université Paris-Saclay, Inria, LMS Polytechnique and M3DISIM, Palaiseau, France
| | - Elsa Manquat
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- AP-HP-Inria, Laboratoire Daniel Bernoulli, Paris, France
| | - Élodie Felliot
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
| | - Fabrice Vallée
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- Université Paris-Saclay, Inria, LMS Polytechnique and M3DISIM, Palaiseau, France
- Université de Paris, Inserm, UMRS 942 Mascot, Paris, France
| | - Alexandre Mebazaa
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- Université de Paris, Inserm, UMRS 942 Mascot, Paris, France
| | - Étienne Gayat
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- Université de Paris, Inserm, UMRS 942 Mascot, Paris, France
| | - Benjamin Glenn Chousterman
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- Université de Paris, Inserm, UMRS 942 Mascot, Paris, France
| | - Romain Barthélémy
- From the Department of Anesthesia and Critical Care, AP-HP, Hôpital Lariboisière, Paris, France
- Université de Paris, Inserm, UMRS 942 Mascot, Paris, France
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Sardesai N, Hibberd O, Price J, Ercole A, Barnard EBG. Agreement between arterial and end-tidal carbon dioxide in adult patients admitted with serious traumatic brain injury. PLoS One 2024; 19:e0297113. [PMID: 38306331 PMCID: PMC10836696 DOI: 10.1371/journal.pone.0297113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/27/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Low-normal levels of arterial carbon dioxide (PaCO2) are recommended in the acute phase of traumatic brain injury (TBI) to optimize oxygen and CO2 tension, and to maintain cerebral perfusion. End-tidal CO2 (ETCO2) may be used as a surrogate for PaCO2 when arterial sampling is less readily available. ETCO2 may not be an adequate proxy to guide ventilation and the effects on concomitant injury, time, and the impact of ventilatory strategies on the PaCO2-ETCO2 gradient are not well understood. The primary objective of this study was to describe the correlation and agreement between PaCO2 and ETCO2 in intubated adult trauma patients with TBI. METHODS This study was a retrospective analysis of prospectively-collected data of intubated adult major trauma patients with serious TBI, admitted to the East of England regional major trauma centre; 2015-2019. Linear regression and Welch's test were performed on each cohort to assess correlation between paired PaCO2 and ETCO2 at 24-hour epochs for 120 hours after admission. Bland-Altman plots were constructed at 24-hour epochs to assess the PaCO2-ETCO2 agreement. RESULTS 695 patients were included, with 3812 paired PaCO2 and ETCO2 data points. The median PaCO2-ETCO2 gradient on admission was 0.8 [0.4-1.4] kPa, Bland Altman Bias of 0.96, upper (+2.93) and lower (-1.00), and correlation R2 0.149. The gradient was significantly greater in patients with TBI plus concomitant injury, compared to those with isolated TBI (0.9 [0.4-1.5] kPa vs. 0.7 [0.3-1.1] kPa, p<0.05). Across all groups the gradient reduced over time. Patients who died within 30 days had a larger gradient on admission compared to those who survived; 1.2 [0.7-1.9] kPa and 0.7 [0.3-1.2] kPa, p<0.005. CONCLUSIONS Amongst adult patients with TBI, the PaCO2-ETCO2 gradient was greater than previously reported values, particularly early in the patient journey, and when associated with concomitant chest injury. An increased PaCO2-ETCO2 gradient on admission was associated with increased mortality.
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Affiliation(s)
- Neil Sardesai
- Emmanuel College, University of Cambridge, Cambridge, United Kingdom
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre for Artificial Intelligence in Medicine, Cambridge, United Kingdom
| | - Owen Hibberd
- Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - James Price
- Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre for Artificial Intelligence in Medicine, Cambridge, United Kingdom
| | - Ed B. G. Barnard
- Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, United Kingdom
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Upchurch CP, Wessman BT, Roberts BW, Fuller BM. Arterial to end-tidal carbon dioxide gap and its characterization in mechanically ventilated adults in the emergency department. Am J Emerg Med 2023; 73:154-159. [PMID: 37683313 DOI: 10.1016/j.ajem.2023.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE To evaluate early measurement of the arterial to end-tidal carbon dioxide (PaCO2-PetCO2) gap, a surrogate for physiologic dead space, and its association with clinical outcomes in intubated adults in the emergency department (ED). MATERIALS AND METHODS Observational cohort study of invasively mechanically ventilated adults in an academic medical center (years 2009 to 2016). The association of the PaCO2-PetCO2 gap was evaluated with respect to clinical outcomes; the primary outcome was in-hospital mortality. RESULTS 519 patients were included. 325 (63%) patients had an elevated (>5 mmHg) PaCO2-PetCO2. Patients with an elevated PaCO2-PetCO2 were significantly older, had higher APACHE II scores, more frequently had chronic obstructive pulmonary disease (COPD), had lower arterial oxygen to fraction of inspired oxygen (P:F) ratios, and were more likely to be intubated for exacerbation of COPD or sepsis. There was no difference in mortality for patients with an elevated PaCO2-PetCO2 (25% vs 26%) in unadjusted analysis (p = 0.829) or adjusted analysis (aOR = 0.81 [95% CI: 0.53-1.26]), as compared to a non-elevated PaCO2-PetCO2. CONCLUSIONS An elevated PaCO2-PetCO2 gap is common in the post-intubation period in the ED, but not significantly associated with clinical outcomes.
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Affiliation(s)
- Cameron P Upchurch
- Department of Medicine, Division of Pulmonary and Critical Care. MSC 8052-43-14. Washington University School of Medicine. 660 S. Euclid Ave. St. Louis, MO 63110, USA.
| | - Brian T Wessman
- Department of Emergency Medicine 660 S. Euclid Ave Campus Box 8072 St. Louis, MO 63110, USA; Department of Anesthesiology, Division of Critical Care 660 S. Euclid Ave. St. Louis, MO 63110, USA
| | - Brian W Roberts
- Cooper University Hospital Department of Emergency Medicine One Cooper Plaza Camden, NJ 08103, USA
| | - Brian M Fuller
- Department of Emergency Medicine 660 S. Euclid Ave Campus Box 8072 St. Louis, MO 63110, USA; Department of Anesthesiology, Division of Critical Care 660 S. Euclid Ave. St. Louis, MO 63110, USA
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Bossers SM, Mansvelder F, Loer SA, Boer C, Bloemers FW, Van Lieshout EMM, Den Hartog D, Hoogerwerf N, van der Naalt J, Absalom AR, Schwarte LA, Twisk JWR, Schober P. Association between prehospital end-tidal carbon dioxide levels and mortality in patients with suspected severe traumatic brain injury. Intensive Care Med 2023; 49:491-504. [PMID: 37074395 DOI: 10.1007/s00134-023-07012-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/19/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE Severe traumatic brain injury is a leading cause of mortality and morbidity, and these patients are frequently intubated in the prehospital setting. Cerebral perfusion and intracranial pressure are influenced by the arterial partial pressure of CO2 and derangements might induce further brain damage. We investigated which lower and upper limits of prehospital end-tidal CO2 levels are associated with increased mortality in patients with severe traumatic brain injury. METHODS The BRAIN-PROTECT study is an observational multicenter study. Patients with severe traumatic brain injury, treated by Dutch Helicopter Emergency Medical Services between February 2012 and December 2017, were included. Follow-up continued for 1 year after inclusion. End-tidal CO2 levels were measured during prehospital care and their association with 30-day mortality was analyzed with multivariable logistic regression. RESULTS A total of 1776 patients were eligible for analysis. An L-shaped association between end-tidal CO2 levels and 30-day mortality was observed (p = 0.01), with a sharp increase in mortality with values below 35 mmHg. End-tidal CO2 values between 35 and 45 mmHg were associated with better survival rates compared to < 35 mmHg. No association between hypercapnia and mortality was observed. The odds ratio for the association between hypocapnia (< 35 mmHg) and mortality was 1.89 (95% CI 1.53-2.34, p < 0.001) and for hypercapnia (≥ 45 mmHg) 0.83 (0.62-1.11, p = 0.212). CONCLUSION A safe zone of 35-45 mmHg for end-tidal CO2 guidance seems reasonable during prehospital care. Particularly, end-tidal partial pressures of less than 35 mmHg were associated with a significantly increased mortality.
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Affiliation(s)
- Sebastiaan M Bossers
- Department of Anesthesiology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Floor Mansvelder
- Department of Anesthesiology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Location VUmc, de Boelelaan 1117, Amsterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, Rotterdam, The Netherlands
| | - Nico Hoogerwerf
- Department of Anesthesiology, Radboud Unversity Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
- Helicopter Emergency Medical Service Lifeliner 3, Zeelandsedijk 10, Volkel, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Helicopter Emergency Medical Service Lifeliner 1, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, De Boelelaan 1089a, Amsterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Helicopter Emergency Medical Service Lifeliner 1, De Boelelaan 1117, Amsterdam, The Netherlands
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Liu P, Baker Z, Li Y, Li Y, Xu J, Park DC, Welch BG, Pinho M, Pillai JJ, Hillis AE, Mori S, Lu H. CVR-MRICloud: An online processing tool for CO2-inhalation and resting-state cerebrovascular reactivity (CVR) MRI data. PLoS One 2022; 17:e0274220. [PMID: 36170233 PMCID: PMC9518872 DOI: 10.1371/journal.pone.0274220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/23/2022] [Indexed: 12/02/2022] Open
Abstract
Cerebrovascular Reactivity (CVR) provides an assessment of the brain's vascular reserve and has been postulated to be a sensitive marker in cerebrovascular diseases. MRI-based CVR measurement typically employs alterations in arterial carbon dioxide (CO2) level while continuously acquiring Blood-Oxygenation-Level-Dependent (BOLD) images. CO2-inhalation and resting-state methods are two commonly used approaches for CVR MRI. However, processing of CVR MRI data often requires special expertise and may become an obstacle in broad utilization of this promising technique. The aim of this work was to develop CVR-MRICloud, a cloud-based CVR processing pipeline, to enable automated processing of CVR MRI data. The CVR-MRICloud consists of several major steps including extraction of end-tidal CO2 (EtCO2) curve from raw CO2 recording, alignment of EtCO2 curve with BOLD time course, computation of CVR value on a whole-brain, regional, and voxel-wise basis. The pipeline also includes standard BOLD image processing steps such as motion correction, registration between functional and anatomic images, and transformation of the CVR images to canonical space. This paper describes these algorithms and demonstrates the performance of the CVR-MRICloud in lifespan healthy subjects and patients with clinical conditions such as stroke, brain tumor, and Moyamoya disease. CVR-MRICloud has potential to be used as a data processing tool for a variety of basic science and clinical applications.
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Affiliation(s)
- Peiying Liu
- Department of Diagnostic Radiology & Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Zachary Baker
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Yue Li
- AnatomyWorks, LLC, Baltimore, Maryland, United States of America
| | - Yang Li
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jiadi Xu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, Maryland, United States of America
| | - Denise C. Park
- Center for Vital Longevity, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, Texas, United States of America
| | - Babu G. Welch
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Marco Pinho
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Jay J. Pillai
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Argye E. Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Susumu Mori
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, Maryland, United States of America
| | - Hanzhang Lu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, Maryland, United States of America
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Wang J, Zhang J, Liu Y, Shang H, Peng L, Cui Z. Relationship between end-tidal carbon dioxide and arterial carbon dioxide in critically ill patients on mechanical ventilation: A cross-sectional study. Medicine (Baltimore) 2021; 100:e26973. [PMID: 34414969 PMCID: PMC8376328 DOI: 10.1097/md.0000000000026973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 08/01/2021] [Indexed: 01/04/2023] Open
Abstract
So far, only a few studies have examined and confirmed the correlation between end-expiratory carbon dioxide partial pressure (PETCO2) and arterial carbon dioxide tension (PaCO2) during invasive mechanical ventilation in critically ill patients. This study aimed to observe the correlation between PaCO2 and PETCO2 in patients on invasive mechanical ventilation.This was a cross-sectional study of adult patients on invasive mechanical ventilation enrolled between June 2018 and March 2019. Patients requiring invasive mechanical ventilation underwent one of the following mechanical ventilation modes: assisted/controlled ventilation, synchronized intermittent mandatory ventilation, and spontaneous breathing. Subsequently, the difference and correlation between PETCO2 and PaCO2 were analyzed.A total of 184 patients with 298 pairs of PETCO2-PaCO2 data were included in the analysis. Without distinguishing the ventilator mode, there was significant positive correlation between PETCO2 and PaCO2. In different ventilator modes, the correlation coefficient was 0.81 for synchronized intermittent mandatory ventilation, 0.47 for assisted/controlled ventilation, and 0.55 for spontaneous breathing, respectively. In patients with chronic obstructive pulmonary disease (r = 0.80), multiple trauma (r = 0.64), severe pneumonia (r = 0.60), gastrointestinal surgery (r = 0.57), and cerebrovascular diseases (r = 0.53), PETCO2 and PaCO2 were positively correlated. For oxygenation index <200 mm Hg, correlation coefficient r = 0.69, P < .001; oxygenation index ≥200, r = 0.73, P < .001. Under different oxygenation indexes, there was no statistically significant difference between the 2 correlation coefficients. Among 116 pairs of data with oxygenation index <200 mm Hg, the difference of PaCO2-PETCO2 ≥10 mm Hg was found in 25 pairs (21.55%); in 182 pairs of data with oxygenation index ≥200 mm Hg, the difference of PaCO2-PETCO2 ≥10 mm Hg was found in 26 pairsIn patients on invasive mechanical ventilation, there was a good correlation between PETCO2 and PaCO2 in different ventilator modes, different disease types, and different oxygenation indexes, especially in synchronized intermittent mandatory ventilation mode and chronic obstructive pulmonary disease patients.
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Abdel-Ghaffar HS, Bakr MAM, Osman MAK, Hanna SGL, Ali WN. End-tidal carbon dioxide measurements as a surrogate to arterial carbon dioxide during pediatric laparoscopic surgeries: a prospective observational cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021:S0104-0014(21)00326-2. [PMID: 34411630 DOI: 10.1016/j.bjane.2021.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Maintaining normocapnia during mechanical ventilation in anesthetized children during laparoscopic surgeries is highly recommended. There is a debate regarding the use of capnography (ETCO2) as a trend monitor for evaluation of arterial carbon dioxide levels (PaCO2). We analyzed the relationship between ETCO2 and PaCO2 with time in elective pediatric laparoscopic surgeries. METHODS This study was a prospective observational cohort analysis of 116 paired comparisons between PaCO2 and ETCO2 computed from 29 children (ASA I, 12-72 months). Arterial blood samples were withdrawn before, at 15 minutes and 30 minutes during pneumoperitoneum and 1 minute after deflation. ETCO2 value was recorded simultaneously, while arterial blood was withdrawn. PaCO2-ETCO2 relationship was evaluated by Pearson's correlation coefficients and Bland Altman Method of agreement. RESULTS Out of the 116 comparisons analyzed, a PaCO2-ETCO2 difference beyond 0 to ≤ 5 mmHg was recorded in 71 comparisons (61.2%) with negative difference in 34 comparisons (29.3%). A positive significant correlation between PaCO2 and ETCO2 was recorded before (r = 0.617, p = 0.000) and at 15 minutes (r = 0.582, p = 0.001), with no significant correlation at 30 minutes (r = 0.142, p = 0.461), either after deflation (r = 0.108, p = 0.577). Bland-Altman plots showed agreement between ETCO2 and PaCO2 before inflation with mean PaCO2-ETCO2 difference 0.14 ± 5.6 mmHg (limits of 95% agreement -10.84-11.2, simple linear regression testing p-value 0.971), with no agreement at 15 minutes (0.51 ± 7.15, -13.5-14.5, p = 0.000), 30 minutes. (2.62 ± 7.83, -12.73-17.97, p = 0.000), or after deflation (1.81 ± 6.56, -10.93-14.55, p = 0.015). CONCLUSION Usage of capnography as a trend monitor in pediatric laparoscopic surgeries may not be a reliable surrogate for PaCO2 levels. TRIAL REGISTRATION Clinical Trials. gov (Identifier: NCT03361657).
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Affiliation(s)
- Hala Saad Abdel-Ghaffar
- Assiut University, Faculty of Medicine, Anesthesia and Intensive Care Department, Assiut, Egypt.
| | | | | | | | - Wesam Nashat Ali
- Assiut University, Faculty of Medicine, Anesthesia and Intensive Care Department, Assiut, Egypt
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8
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Hotta M, Hirata K, Nozaki M, Mochizuki N, Hirano S, Wada K. Availability of portable capnometers in children with tracheostomy. Pediatr Int 2021; 63:833-837. [PMID: 33078497 DOI: 10.1111/ped.14516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/01/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND A capnometer is a noninvasive monitor that is used to assess patients' respiratory status. This study was performed to evaluate the availability of a portable capnometer in children with tracheostomy. METHODS This retrospective study included children with tracheostomy who were treated at the Osaka Women's and Children's Hospital Osaka, Japan, from 1 September 2018 to 31 October 2019. We assessed the correlation between the partial pressure of venous carbon dioxide (PvCO2 ) and end-tidal carbon dioxide tension (EtCO2 ) using a portable capnometer (EMMA; Masimo, Irvine, CA, USA). RESULTS Nine infants and 43 simultaneous PvCO2 -EtCO2 pairs were analyzed. The correlation coefficient of these pairs was 0.87 (95% confidence interval, 0.77-0.93; P < 0.001). The Bland-Altman plot showed that EtCO2 was on average 10.0 mmHg lower than its paired PvCO2 value (95% limits of agreement, 1.0-19.1). The difference between PvCO2 and EtCO2 was significantly greater in patients on ventilators. CONCLUSIONS The portable capnometer evaluated in this study (EMMA) was readily available and useful for assessment of the respiratory condition in children with tracheostomy.
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Affiliation(s)
- Masashi Hotta
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Masatoshi Nozaki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Narutaka Mochizuki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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Doppmann P, Meuli L, Sollid SJM, Filipovic M, Knapp J, Exadaktylos A, Albrecht R, Pietsch U. End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study. Sci Rep 2021; 11:10391. [PMID: 34001982 PMCID: PMC8129079 DOI: 10.1038/s41598-021-89913-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022] Open
Abstract
Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO2 as a proxy for PaCO2. We assessed whether the difference between end tidal CO2 and PaCO2 at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO2 gap-defined as the difference between end tidal CO2 and PaCO2-and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO2 gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO2 and PaCO2 at admission was low (Pearson's r = .287). The mean CO2 gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO2 gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO2 gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO2 and PaCO2 is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO2 was significantly lower than PaCO2, making it an unreliable proxy for PaCO2 when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.
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Affiliation(s)
- Pascal Doppmann
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Miodrag Filipovic
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland
| | - Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, FreiburgstrasseBern, Switzerland
| | - Roland Albrecht
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, FreiburgstrasseBern, Switzerland
- Swiss Air-Ambulance, Rega (RettungsFlugwacht/Guarde Aérienne), Postfach 1414, 8058, Zurich, Switzerland
| | - Urs Pietsch
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland.
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, FreiburgstrasseBern, Switzerland.
- Swiss Air-Ambulance, Rega (RettungsFlugwacht/Guarde Aérienne), Postfach 1414, 8058, Zurich, Switzerland.
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11
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 170] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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12
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Price J, Sandbach DD, Ercole A, Wilson A, Barnard EBG. End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study. Emerg Med J 2020; 37:674-679. [PMID: 32928874 PMCID: PMC7588597 DOI: 10.1136/emermed-2019-209077] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 07/08/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0-4.5 kPa (30.0-33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO2-PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO2-PaCO2 gradient of TBI patients at hospital arrival. METHODS A retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% CI. ETCO2-PaCO2 gradient data were compared with a two-tailed, unpaired, t-test. RESULTS 107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and -0.2 (95% CI -0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2-PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg). CONCLUSION There is only moderate correlation of ETCO2 and PaCO2 at hospital arrival in patients with serious TBI. The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO2 measurement.
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Affiliation(s)
- James Price
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
| | - Daniel D Sandbach
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Ari Ercole
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Alastair Wilson
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department (Retired), Royal London Hospital, London, UK
| | - Ed Benjamin Graham Barnard
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
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13
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Krishnamoorthy A, Meher BK, Damayanty Pradhan D, Satpathy SK. Capnography in Pediatric Critical Care Unit and Correlation of End-Tidal and Arterial Carbon Dioxide in Ventilated Children. JOURNAL OF CHILD SCIENCE 2020. [DOI: 10.1055/s-0040-1714114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractRecording of end-tidal carbon dioxide (EtCO2) noninvasively reflects a real-time estimation of arterial carbon dioxide (PaCO2 [partial pressure of CO2]). However, as the EtCO2 is dependent on metabolism, perfusion, and ventilation, predicting PaCO2 from EtCO2 is not linear. The objective of the study was to find out the predictability of PaCO2 from EtCO2 in PICU and to evaluate the factors affecting the correlation of EtCO2 and PaCO2 in critically ill ventilated children. The design involved was prospective observational study. The setting discussed over here is that of pediatric intensive care unit (PICU) of tertiary care hospital. A total of 160 children between 1 month and 14 years received mechanical ventilation. EtCO2, PaCO2, PaO2/FiO2 (PF) ratio, oxygenation index (OI), and ventilation index (VI) are the factors involved in main outcome measures. A total of 535 pairs of EtCO2 and PaCO2 were recorded in 160 ventilated children during the stable hemodynamic state. Mean age and weight (Z-score) of patients were 31.15 ± 40.46 months and −2.10 ± 1.58, respectively. EtCO2 and PaCO2 differences were normal (2–5 mm of Hg) in 393 (73.5%) pairs. High gradient (>5 mm of Hg) was mostly found with children with pneumonia, prolonged ventilation, and pressure mode of ventilation (p < 0.05). EtCO2 had a strong positive correlation with PaCO2 (r = 0.723, 95% confidence interval [CI] = 0.68 and 0.76) and not significantly affected by PF ratio or OI. However, presence of pneumonia and high ventilation index (VI > 20) adversely affected the relationship with poor correlation coefficient (r = 0.449, 95% CI = 0.30, 0.58 and r = 0.227, 95% CI = 0.03, 0.41, respectively). EtCO2 reading showed good validity to predict PaCO2 and not affected by oxygenation parameters. The correlation was affected by the presence of pneumonia and high ventilation index; hence it is recommended to monitor PaCO2 invasively in these patients till a good correlation is established.
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14
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Tasker RC. Traumatic Brain Injury and Pediatric Acute Respiratory Distress Syndrome: Moving the Field Forward. Pediatr Crit Care Med 2020; 21:198-199. [PMID: 32032266 DOI: 10.1097/pcc.0000000000002181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert C Tasker
- Department of Neurology; and Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School and Boston Children's Hospital, Boston, MA
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