1
|
Cáceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñan Garcés AE, González A, Alvarado Arias A, Bhatia K, Samadani U, Reyes LF. PaCO 2 Association with Outcomes of Patients with Traumatic Brain Injury at High Altitude: A Prospective Single-Center Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-01982-8. [PMID: 38740704 DOI: 10.1007/s12028-024-01982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. METHODS This is a prospective single-center cohort of consecutive patients with TBI admitted to a trauma center located at 2600 m above sea level. An unfavorable outcome was defined as a Glasgow Outcome Scale-Extended (GOSE) score < 4 at the 6-month follow-up. RESULTS We had a total of 81 patients with complete data, 80% (65/81) were men, and the median (interquartile range) age was 36 (25-50) years. Median Glasgow Coma Scale (GCS) score on admission was 9 (6-14); 49% (40/81) of patients had severe TBI (GCS 3-8), 32% (26/81) had moderate TBI (GCS 12-9), and 18% (15/81) had mild TBI (GCS 13-15). The median (interquartile range) Abbreviated Injury Score of the head (AISh) was 3 (2-4). The frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), the median GOSE was 4 (2-5), and the median 6-month mortality rate was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, (median age 49 [30-72] vs. 29 [22-41] years, P < 0.01), had lower admission GCS scores (6 [4-8] vs. 13 [8-15], P < 0.01), had higher AISh scores (4 [4-4] vs. 3 [2-4], P < 0.01), had higher Acute Physiology and Chronic Health disease Classification System II scores (17 [15-23] vs. 10 [6-14], P < 0.01), had higher Charlson scores (0 [0-2] vs. 0 [0-0], P < 0.01), and had higher PaCO2 levels (mean 35 ± 8 vs. 32 ± 6 mm Hg, P < 0.01). In a multivariate analysis, age (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.1-1.30, P < 0.01), AISh (OR 4.7, 95% CI 1.55-21.0, P < 0.05), and PaCO2 levels (OR 1.23, 95% CI 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4, 95% CI 1.61-28.5, P = 0.017) and PaCO2 levels (OR 1.36, 95% CI 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. CONCLUSIONS Higher PaCO2 levels are associated with an unfavorable outcome in ventilated patients with TBI. These results underscore the importance of PaCO2 levels in patients with TBI and whether it should be adjusted for populations living at higher altitudes.
Collapse
Affiliation(s)
- Eder Cáceres
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia.
- Department of Bioscience, School of Engineering, Universidad de La Sabana, Chía, Colombia.
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia.
| | - Afshin A Divani
- Department of Neurology, The University of New Mexico, Albuquerque, NM, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Juan Olivella-Gómez
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Angélica González
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Uzma Samadani
- Department of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Luis F Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| |
Collapse
|
2
|
Schober P, Bossers SM, Bulte CSE, Loer SA, Schwarte LA. Relationship between the arterial partial pressure of carbon dioxide and outcomes in mechanically ventilated acute brain‑injured patients. Intensive Care Med 2024; 50:796-797. [PMID: 38630287 DOI: 10.1007/s00134-024-07421-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Sebastiaan M Bossers
- Department of Anesthesiology, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Carolien S E Bulte
- Department of Anesthesiology, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Robba C, Taccone FS, Cinotti R, Asehnoune K, Badenes R. Mild hypocapnia and outcomes in mechanically ventilated acute brain-injured patients: another piece in the puzzle. Intensive Care Med 2024; 50:798-799. [PMID: 38630286 DOI: 10.1007/s00134-024-07436-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
- UMR 1246 SPHERE "MethodS in Patients-Centered Outcomes and HEalth Research", University of Nantes, University of Tours, INSERM, IRS2 22 Boulevard Benoni Goulin, 44200, Nantes, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
| | - Rafael Badenes
- Department of Surgery, University of Valencia, Valencia, Spain
| |
Collapse
|
4
|
Mansvelder FJ, Bossers SM, Loer SA, Bloemers FW, Van Lieshout EMM, Den Hartog D, Hoogerwerf N, van der Naalt J, Absalom AR, Peerdeman SM, Bulte CSE, Schwarte LA, Schober P. Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury. Anesthesiology 2024; 140:742-751. [PMID: 38190220 DOI: 10.1097/aln.0000000000004894] [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: 01/09/2024]
Abstract
BACKGROUND Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands. METHODS This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis. RESULTS In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data. CONCLUSIONS The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Floor J Mansvelder
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sebastiaan M Bossers
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nico Hoogerwerf
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 3, Volkel, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Saskia M Peerdeman
- Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, The Netherlands
| | - Carolien S E Bulte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Helicopter Emergency Medical Service Lifeliner 1, Amsterdam, The Netherlands; and Department of Neurosurgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, The Netherlands
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Robba C, Battaglini D, Abbas A, Sarrió E, Cinotti R, Asehnoune K, Taccone FS, Rocco PR, Schultz MJ, Citerio G, Stevens RD, Badenes R. Clinical practice and effect of carbon dioxide on outcomes in mechanically ventilated acute brain-injured patients: a secondary analysis of the ENIO study. Intensive Care Med 2024; 50:234-246. [PMID: 38294526 PMCID: PMC10907416 DOI: 10.1007/s00134-023-07305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/09/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE The use of arterial partial pressure of carbon dioxide (PaCO2) as a target intervention to manage elevated intracranial pressure (ICP) and its effect on clinical outcomes remain unclear. We aimed to describe targets for PaCO2 in acute brain injured (ABI) patients and assess the occurrence of abnormal PaCO2 values during the first week in the intensive care unit (ICU). The secondary aim was to assess the association of PaCO2 with in-hospital mortality. METHODS We carried out a secondary analysis of a multicenter prospective observational study involving adult invasively ventilated patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), or ischemic stroke (IS). PaCO2 was collected on day 1, 3, and 7 from ICU admission. Normocapnia was defined as PaCO2 > 35 and to 45 mmHg; mild hypocapnia as 32-35 mmHg; severe hypocapnia as 26-31 mmHg, forced hypocapnia as < 26 mmHg, and hypercapnia as > 45 mmHg. RESULTS 1476 patients (65.9% male, mean age 52 ± 18 years) were included. On ICU admission, 804 (54.5%) patients were normocapnic (incidence 1.37 episodes per person/day during ICU stay), and 125 (8.5%) and 334 (22.6%) were mild or severe hypocapnic (0.52 and 0.25 episodes/day). Forced hypocapnia and hypercapnia were used in 40 (2.7%) and 173 (11.7%) patients. PaCO2 had a U-shape relationship with in-hospital mortality with only severe hypocapnia and hypercapnia being associated with increased probability of in-hospital mortality (omnibus p value = 0.0009). Important differences were observed across different subgroups of ABI patients. CONCLUSIONS Normocapnia and mild hypocapnia are common in ABI patients and do not affect patients' outcome. Extreme derangements of PaCO2 values were significantly associated with increased in-hospital mortality.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Abbas Abbas
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy
| | - Ezequiel Sarrió
- Department of Surgery, University of Valencia, Valencia, Spain
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
- UMR 1246 SPHERE "MethodS in Patients-Centered Outcomes and HEalth Research", INSERM, IRS2 22 Boulevard Benoni Goulin, University of Nantes, University of Tours, 44200, Nantes, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Patricia R Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Rio de Janeiro, Brazil
| | - Marcus J Schultz
- Department of Clinical Medicine, University of Oxford Nuffield, Oxford, Oxfordshire, 105596, UK
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Neurosciences, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Robert David Stevens
- Department of Anesthesiology and Critical Care, John Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
| | - Rafael Badenes
- Department of Surgery, University of Valencia, Valencia, Spain
- Department Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| |
Collapse
|
7
|
Caceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñán-Garcés AE, González A, Alvarado-Arias A, Bathia K, Samadani U, Reyes LF. PaCO2 Association with Traumatic Brain Injury Patients Outcomes at High Altitude: A Prospective Single-Center Cohort Study. RESEARCH SQUARE 2024:rs.3.rs-3876988. [PMID: 38343855 PMCID: PMC10854293 DOI: 10.21203/rs.3.rs-3876988/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. Methods This is a prospective single-center cohort of consecutive TBI patients admitted to a trauma center located at 2600 meter above sea level. An unfavorable outcome was defined as the Glasgow Outcome Scale-Extended (GOSE) < 4 at 6-month follow-up. Results 81 patients with complete data, 80% (65/81) were men, and median (IQR) age was 36 (25-50) years). Median Glasgow Coma Scale (GCS) on admission was 9 (6-14), 49% (40/81) were severe (GCS: 3-8), 32% (26/81) moderate (GCS 12 - 9), and 18% (15/81) mild (GCS 13-15) TBI. The median (IQR) Abbreviated Injury Score of the Head (AISh) was 3 (2-4). Frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), median GOSE was 4 (2-5), and 6-month mortality was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, median [49 (30-72) vs. 29 (22-41), P < 0.01], had lower admission GCS [6 (4-8) vs. 13 (8-15), P < 0.01], higher AIS head [4 (4-4) vs. 3(2-4), p < 0.01], higher APACHE II score [17(15-23) vs 10 (6-14), < 0.01), higher Charlson score [0(0-2) vs. 0 (0-0), P < 0.01] and higher PaCO2 (mmHg), mean ± SD, 39 ± 9 vs. 32 ± 6, P < 0.01. In a multivariate analysis, age (OR 1.14 95% CI 1.1-1.30, P < 0.01), AISh (OR 4.7 95% CI 1.55-21.0, P < 0.05), and PaCO2 (OR 1.23 95% CI: 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4 95% CI: 1.61-28.5, P = 0.017) and PaCO2 (OR 1.36 95% CI: 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. Conclusion Higher PaCO2 levels are associated with an unfavorable outcome in ventilated TBI patients. These results underscore the importance of PaCO2 level in TBI patients and whether it should be adjusted for populations living at higher altitudes.
Collapse
Affiliation(s)
| | - Afshin A Divani
- University of New Mexico - Albuquerque: The University of New Mexico
| | - Clio A Rubinos
- University of North Carolina at Chapel Hill Health Sciences Library: The University of North Carolina at Chapel Hill
| | | | | | | | - Alexis Alvarado-Arias
- University of Mississippi University Hospital: The University of Mississippi Medical Center
| | - Kunal Bathia
- University of Mississippi University Hospital: The University of Mississippi Medical Center
| | | | | |
Collapse
|
8
|
Walther LH, Lassen AT, Mogensen CB, Christensen EF, Mikkelsen S. Prehospital blood gas analyses in acute patients treated by a ground-based physician-manned emergency unit: a cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:102. [PMID: 38115069 PMCID: PMC10729417 DOI: 10.1186/s13049-023-01170-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The prehospital patients treated by ambulances and mobile emergency care units (MECU) are potentially critically ill or injured. Knowing the risks of serious outcomes in these patients is important for guiding their treatment. Some settings allow for prehospital arterial blood gas analyses. This study aimed to assess the outcomes of prehospital patients in relation to their prehospitally measured lactate, pH, and CO2 levels. The primary outcome was 7-day mortality. METHODS This register-based cohort study included patients with one or more prehospital blood gas analyses during their prehospital treatment by a physician-manned MECU, from January 2015 to December 2018. The blood samples were analyzed on an ABL90 Flex analyzer. Absolute values with percentages and odds ratios (OR) with 95% confidence intervals (CI) were calculated for the primary and secondary outcomes within prespecified subgroups. RESULTS The study included 745 patients, with an overall 7-day mortality rate of 20.0%. LACTATE LEVEL The 7-day mortality rates were 11.5% in patients with normal lactate levels (< 2.0 mmol/L), 14.4% with intermediate lactate levels (2.0-3.9 mmol/L), and 33.0% with high lactate levels (≥ 4.0 mmol/L). This corresponded to an OR of 1.30 (95% CI: 0.75-2.24) in the intermediate lactate group (2.0-3.9 mmol/L) and an OR of 3.77 (95% CI: 2.44-5.85) in the high lactate group (≥ 4.0 mmol/L), compared to the reference group with normal lactate. PH LEVEL The ORs of 7-day mortality rates were 4.82 (95% CI: 3.00-7.75) in patients with blood pH of < 7.35 and 1.33 (95% CI: 0.65-2.72) in patients with blood pH > 7.45, compared to the reference group with normal pH (7.35-7.45). CO2 LEVEL : The ORs of 7-day mortality rates were 2.54 (95% CI: 1.45-4.46) in patients with blood CO2 of < 4.3 kPa and 2.62 (95% CI: 1.70-4.03) in patients with blood CO2 > 6.0 kPa, compared to the reference group with normal CO2 (4.3-6.0 kPa). CONCLUSIONS This study found a strong correlation between increasing 7-day mortality rates and high blood lactate levels, low levels of pH, and abnormal CO2 blood levels, in prehospital patients undergoing prehospital blood analysis.
Collapse
Affiliation(s)
- Louise Houlberg Walther
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | | | - Christian Backer Mogensen
- Emergency Medicine Research Unit, Hospital Soenderjylland, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Institute of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Emergency and Trauma Care, Center for Internal Medicine and Emergency Care, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
9
|
Shukla G, Parks K, Smith DW, Hartings JA. Impact of Hypo- and Hyper-capnia on Spreading Depolarizations in Rat Cerebral Cortex. Neuroscience 2023; 530:46-55. [PMID: 37640133 DOI: 10.1016/j.neuroscience.2023.08.029] [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: 06/19/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
Patients with traumatic brain injury are typically maintained at low-normal levels of arterial partial pressure of carbon dioxide (PaCO2) to counteract the risk of elevated intracranial pressure during intensive care. However, several studies suggest that management at hypercarbic levels may have therapeutic benefit. Here we examined the impact of CO2 levels on spreading depolarizations (SD), a mechanism and marker of acute lesion development in stroke and brain trauma. In an acute preparation of mechanically ventilated (30/70 O2/N2) female rats, SDs were evoked by cortical KCl application and monitored by electrophysiology and laser doppler flowmetry; CO2 levels were adjusted by ventilator settings and supplemental CO2. During 90 min of KCl application, rats were maintained at hypocapnia (end-tidal CO2 22 ± 2 mmHg) or hypercapnia (57 ± 4 mmHg) but did not differ significantly in arterial pH (7.31 ± 0.10 vs. 7.22 ± 0.08, p = 0.31) or other variables. Surprisingly, there was no difference between groups in the number of SDs recorded (10.7 ± 4.2 vs. 11.7 ± 3.1; n = 3 rats/group; p = 0.75) nor in SD durations (64 ± 27 vs. 69 ± 37 sec, p = 0.54). In separate experiments (n = 3), hypoxia was induced by decreasing inhaled O2 to 10% and single SDs were induced under interleaved conditions of hypo-, normo-, and hypercapnia. No differences in SD duration were observed. In both normoxia and hypoxia experiments, however, mean arterial pressures were negatively correlated with SD durations (normoxia R2 = -0.29; hypoxia R2 = -0.61, p's < 0.001). Our results suggest that any therapeutic benefit of elevated CO2 therapy may be dependent on an acidic shift in pH or may only be observed in conditions of focal brain injury.
Collapse
Affiliation(s)
- Geet Shukla
- University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Ken Parks
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | | | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA.
| |
Collapse
|
10
|
Olasveengen TM, Stocchetti N. Prehospital ventilation targets in severe traumatic brain injury. Intensive Care Med 2023; 49:554-555. [PMID: 37060441 DOI: 10.1007/s00134-023-07044-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Theresa Mariero Olasveengen
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway.
| | - Nino Stocchetti
- Fondazione IRCCS Cà Granda Ospedale Maggior Policlinico, Milan and Department of Physiopathology and Transplant, Milan University, Milan, Italy
| |
Collapse
|