Noninvasive capnometry for end-tidal carbon dioxide monitoring via nasal cannula in nonintubated neonates

Elevation of Pulmonary Artery Pressure in Newborns from High-Altitude Pregnancies Complicated by Preeclampsia

We hypothesized that fetal exposure to the oxidative stress induced by the combined challenge of preeclampsia (PE) and high altitude would induce a significant impairment in the development of pulmonary circulation. We conducted a prospective study in La Paz (Bolivia, mean altitude 3625 m) in which newborns from singleton pregnancies with and without PE were compared (PE group n = 69, control n = 70). We conducted an echocardiographic study in these infants at the median age of two days. The percentage of cesarean deliveries and small for gestational age (SGA) infants was significantly higher in the PE group. Heart rate, respiratory rate, and oxygen saturation did not vary significantly between groups. Estimated pulmonary arterial pressure and pulmonary vascular resistance were 30% higher in newborns exposed to PE and high altitude compared with those exposed only to high altitude. We also detected signs of right ventricular hypertrophy in infants subjected to both exposures. In conclusion, this study provides evidence that the combination of PE and pregnancy at high altitude induces subclinical alterations in the pulmonary circulation of the newborn. Follow-up of this cohort may provide us with valuable information on the potential increased susceptibility to developing pulmonary hypertension or other pulmonary and cardiovascular disorders.

Review of pediatric hypercarbia and intraoperative management

PURPOSE OF REVIEW

Hypercarbia in pediatric patients is an important component of intraoperative management. Despite marked advances in medicine and technology, it is uncertain what the physiological CO2 range in neonates, infants and small children. This data is extrapolated from the adult population. We are going to review advantages and disadvantages of CO2 measurement techniques, causes and systemic effects of hypercarbia. We are going to discuss how to approach management of intraoperative hypercarbia.

RECENT FINDINGS

Although physiological range in this patient population may not be fully understood, it is known that any rapid change from a child's baseline increases risks of complications. Any derangements in CO2 are further compromised by hypoxia, hypotension, hypothermia, anemia, all of which may occur in a dynamic operating room environment.

SUMMARY

Pediatric anesthesiologists and their teams must remain vigilant and anticipate these developments. Care must be taken to avoid any rapid changes in these vulnerable patients to minimize risks of adverse outcomes.

Effects of Sedation and/or Sedation/Analgesic Drugs Administered during Central Venous Catheterization on the Level of End-tidal Carbon Dioxide Measured by Nasal Cannula in Our PICU

Aims and objectives

Sedatives and analgesics are commonly used in pediatric intensive care units during minor invasive procedures. Here, we aimed to measure the changes in end-tidal carbon dioxide (EtCO₂) levels with different sedation/analgesic drug administrations (midazolam, ketamine, midazolam + ketamine/fentanyl) during central venous catheterization.

Materials and methods

This prospective study included 44 patients who needed sedation/analgesia for central venous catheterization. Patients were sedated with midazolam, ketamine, or midazolam + fentanyl/ketamine. End-tidal carbon dioxide values were measured before and after sedation-analgesia with nasal cannula and recorded from the capnograph. Oxygen saturation (SO₂) was monitored by pulse oximetry. Whether respiratory depression occurred during the process was recorded.

Results

During the procedure, 15 (34%) patients were given 0.1 mg/kg dose of midazolam described as group I, 18 (41%) patients were given 1 mg/kg dose of ketamine only described as group II, and 11 (25%) patients who could not be effective sedated with a single sedative-analgesic agent were given either 1 mg/kg dose of ketamine or 2 μg/kg dose of fentanyl together with 0.1 mg/kg dose of midazolam described as group III. According to our findings, hypoxia (54.5%) and hypercarbia (45.5%) were detected higher in group III but it was not statistically significant (p = 0.255, p = 0.364). Hypercarbia was detected in 29.5% patients, in 62% of these patients hypercarbia was accompanied by hypoxia, and 38% had only hypercarbia. When presedation and postsedation EtCO₂ values were compared, we detected a statistically significant difference in all groups.

Conclusion

We detected hypercarbia unaccompanied by hypoxemia in 38% patients. And we think that we have identified these patients early due to measurement of EtCO₂ by nasal cannula. This study demonstrated that EtCO₂ monitoring via nasal cannula is a feasible and practical way to follow ventilation during sedation/analgesia.

How to cite this article

Aslan N, Yildizdas D, Horoz OO, Arslan D, Coban Y, Sertdemir Y. Effects of Sedation and/or Sedation/Analgesic Drugs Administered during Central Venous Catheterization on the Level of End-tidal Carbon Dioxide Measured by Nasal Cannula in Our PICU. Indian J Crit Care Med 2020;24(8):705-708.

Continuous Noninvasive Carbon Dioxide Monitoring in Neonates: From Theory to Standard of Care

Ventilatory support may affect the short- and long-term neurologic and respiratory morbidities of preterm infants. Ongoing monitoring of oxygenation and ventilation and control of adequate levels of oxygen, pressures, and volumes can decrease the incidence of such adverse outcomes. Use of pulse oximetry became a standard of care for titrating oxygen delivery, but continuous noninvasive monitoring of carbon dioxide (CO₂) is not routinely used in NICUs. Continuous monitoring of CO₂ level may be crucial because hypocarbia and hypercarbia in extremely preterm infants are associated with lung and brain morbidities, specifically bronchopulmonary dysplasia, intraventricular hemorrhage, and cystic periventricular leukomalacia. It is shown that continuous monitoring of CO₂ levels helps in maintaining stable CO₂ values within an accepted target range. Continuous monitoring of CO₂ levels can be used in the delivery room, during transport, and in infants receiving invasive or noninvasive respiratory support in the NICU. It is logical to hypothesize that this will result in better outcome for extremely preterm infants. In this article, we review the different noninvasive CO₂ monitoring alternatives and devices, their advantages and disadvantages, and the available clinical data supporting or negating their use as a standard of care in NICUs.

Continuous Capnography in Pediatric Intensive Care

Capnography or end-tidal carbon dioxide (Etco₂) monitoring has a variety of uses in the pediatric intensive care setting. The ability to continuously measure exhaled carbon dioxide can provide vital information about airway, breathing, and circulation in critically ill pediatric patients. Capnography has diagnosis-specific applications for pediatric patients with congenital heart disease, reactive airway disease, neurologic emergencies, and metabolic derangement. This modality allows for noninvasive monitoring and has become the standard of care. This article reviews the basic principles and clinical applications of Etco₂ monitoring in the pediatric intensive care unit.

Delivery room end tidal CO2 monitoring in preterm infants <32 weeks

OBJECTIVES

To determine the feasibility of end tidal (EtCO2) monitoring of preterm infants in the delivery room, to determine EtCO2 levels during delivery room stabilisation, and to examine the incidence of normocapnia (5-8 kPa) on admission to the neonatal intensive care unit in the EtCO2 monitored group compared with a historical cohort without EtCO2 monitoring.

PATIENTS AND METHODS

Preterm infants (<32 weeks) were eligible for inclusion in this observational study. The evolution of EtCO2 values immediately after delivery was assessed and linear least-squares methods were used to fit a line to EtCO2 recordings. The partial pressure of CO2 in blood (PCO2) from the infants who received EtCO2 monitoring was compared with a historical cohort without EtCO2 monitoring.

RESULTS

EtCO2 monitoring was feasible in the delivery room. EtCO2 values were successfully obtained in 39 (88.7%) of the 44 infants included in the study. EtCO2 gradually increased over the first 4 min. Intubated infants had higher EtCO2 values compared with infants who were not intubated, with median (IQR) values of 4.7 (3.3-8.4) kPa versus 3.2 (2.6-4.2) kPa (p=0.05). No difference was found between the proportions of PCO2 values within the range of normocapnia among infants who received EtCO2 monitoring compared with those who did not (56.8% vs 47.9%, p=0.396).

CONCLUSIONS

Delivery room EtCO2 monitoring is feasible and safe. EtCO2 values obtained after birth reflect the establishment of functional residual capacity and effective ventilation. The potential short-term and long-term consequences of EtCO2 monitoring should be established in randomised controlled trials.

A review of carbon dioxide monitoring in preterm newborns in the delivery room

INTRODUCTION

The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements.

AIM

To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room.

METHODS

Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials.

RESULTS

The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B.

DISCUSSION

CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.