1
|
Baumann Melberg M, Flaa A, Øystein Andersen G, Sunde K, Bellomo R, Eastwood G, Mariero Olasveengen T, Qvigstad E. Effects of mild hypercapnia on myocardial injury after out-of-hospital cardiac arrest. A sub-study of the TAME trial. Resuscitation 2024:110295. [PMID: 38936652 DOI: 10.1016/j.resuscitation.2024.110295] [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: 05/06/2024] [Revised: 06/21/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Mild hypercapnia did not improve neurological outcomes for resuscitated out-of-hospital cardiac arrest (OHCA) patients in the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. However, the effects of hypercapnic acidosis on myocardial injury in patients with cardiac arrest is unexplored. We investigated whether mild hypercapnia compared to normocapnia, following emergency coronary intervention, increased myocardial injury in comatose OHCA-patients with AMI. METHODS Single-centre, prospective, pre-planned sub-study of the TAME trial. Patients were randomised to targeted mild hypercapnia (PaCO2 =6.7-7.3 kPa) or normocapnia (PaCO2 =4.7-6.0 kPa) for 24 hours. Myocardial injury was assessed with high-sensitive cardiac troponin T (hs-cTnT) measured at baseline, 24, 48 and 72 hours. Haemodynamics were assessed with right heart catheterisation and blood-gas analyses every 4th hour for 48 hours. RESULTS We included 125 OHCA-patients. 57 (46%) had an AMI, with 31 and 26 patients randomised to hypercapnia and normocapnia, respectively. Median peak hs-cTnT in AMI-patients was 58% lower in the hypercapnia-group: 2136 (IQR: 861-4462) versus 5165 ng/L (IQR: 2773-7519), p =0.007. Lower average area under the hs-cTnT curve was observed in the hypercapnia-group: 2353 (95% CI 1388-3319) versus 4953 ng/L (95% CI 3566-6341), P-group =0.002. Hypercapnia was associated with increased cardiac power output (CPO) and lower lactate levels in patients with AMI (P-group <0.05). hs-cTnT, lactate and CPO were not significantly different between intervention groups in OHCA-patients without AMI (p >0.05). CONCLUSIONS Mild hypercapnia was not associated with increased myocardial injury in resuscitated OHCA-patients. In AMI-patients, mild hypercapnia was associated with lower hs-cTnT and lactate, and improved cardiac performance. TRIAL REGISTRATION NUMBER NCT03114033 Take-home-message: In this single-centre, prospective sub-study of a randomised cardiac arrest trial targeting mild hypercapnia was not associated with increased myocardial injury after out-of-hospital cardiac arrest. Compared to targeted normocapnia, mild hypercapnia was associated with lower hs-cTnT levels in patients with acute myocardial infarction as the cause of cardiac arrest.
Collapse
Affiliation(s)
- Mathias Baumann Melberg
- Department of Research and Development, Division of Emergencies and Critical Care, Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo, Norway and Institute of Clinical Medicine, University of Oslo.
| | - Arnljot Flaa
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo
| | | | - Kjetil Sunde
- Department of Anaesthesiology and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway and Institute of Clinical Medicine, University of Oslo
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Melbourne, Australia; Department of Critical Care, Melbourne University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Melbourne, Australia
| | - Theresa Mariero Olasveengen
- Department of Anaesthesiology and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway and Institute of Clinical Medicine, University of Oslo
| | - Eirik Qvigstad
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Frazier AH, Topjian AA, Reeder RW, Morgan RW, Fink EL, Franzon D, Graham K, Harding ML, Mourani PM, Nadkarni VM, Wolfe HA, Ahmed T, Bell MJ, Burns C, Carcillo JA, Carpenter TC, Diddle JW, Federman M, Friess SH, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Meert KL, Naim MY, Notterman D, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Yates AR, Sutton RM, Berg RA. Association of Pediatric Postcardiac Arrest Ventilation and Oxygenation with Survival Outcomes. Ann Am Thorac Soc 2024; 21:895-906. [PMID: 38507645 PMCID: PMC11160133 DOI: 10.1513/annalsats.202311-948oc] [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: 11/08/2023] [Accepted: 03/18/2024] [Indexed: 03/22/2024] Open
Abstract
Rationale: Adult and pediatric studies provide conflicting data regarding whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia, and/or hypocapnia are associated with worse outcomes. Objectives: We sought to determine whether postarrest hypoxemia or postarrest hyperoxemia is associated with lower rates of survival to hospital discharge, compared with postarrest normoxemia, and whether postarrest hypocapnia or hypercapnia is associated with lower rates of survival, compared with postarrest normocapnia. Methods: An embedded prospective observational study during a multicenter interventional cardiopulmonary resuscitation trial was conducted from 2016 to 2021. Patients ⩽18 years old and with a corrected gestational age of ≥37 weeks who received chest compressions for cardiac arrest in one of the 18 intensive care units were included. Exposures during the first 24 hours postarrest were hypoxemia, hyperoxemia, or normoxemia-defined as lowest arterial oxygen tension/pressure (PaO2) <60 mm Hg, highest PaO2 ⩾200 mm Hg, or every PaO2 60-199 mm Hg, respectively-and hypocapnia, hypercapnia, or normocapnia, defined as lowest arterial carbon dioxide tension/pressure (PaCO2) <30 mm Hg, highest PaCO2 ⩾50 mm Hg, or every PaCO2 30-49 mm Hg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. Results: The hypoxemia group was less likely to survive to hospital discharge, compared with the normoxemia group (adjusted relative risk [aRR] = 0.71; 95% confidence interval [CI] = 0.58-0.87), whereas survival in the hyperoxemia group did not differ from that in the normoxemia group (aRR = 1.0; 95% CI = 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge, compared with the normocapnia group (aRR = 0.74; 95% CI = 0.64-0.84), whereas survival in the hypocapnia group did not differ from that in the normocapnia group (aRR = 0.91; 95% CI = 0.74-1.12). Conclusions: Postarrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.
Collapse
Affiliation(s)
- Aisha H. Frazier
- Nemours Cardiac Center, and
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Peter M. Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather A. Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tageldin Ahmed
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Michael J. Bell
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C. Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - J. Wesley Diddle
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Myke Federman
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, California
| | - Stuart H. Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Mark Hall
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio; and
| | - David A. Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M. Horvat
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L. Huard
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, California
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio; and
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Maryam Y. Naim
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Matthew P. Sharron
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, California
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R. Yates
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio; and
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
3
|
Damarlapally N, Sinha T, Rawat A, Soe TM, Munawar G, Chaudhari SS, Wei CR, Ali N. Effects of Targeted Hypercapnia on Mortality and Length of Stay of Post-cardiac Arrest Patients: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e60617. [PMID: 38894798 PMCID: PMC11185866 DOI: 10.7759/cureus.60617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Therapeutic hypercapnia has been proposed as a potential strategy to enhance cerebral perfusion and improve outcomes in patients after cardiac arrest. However, the effects of targeted hypercapnia remain unclear. We conducted a systematic review and meta-analysis to evaluate the impact of hypercapnia compared to normocapnia on mortality and length of stay in post-cardiac arrest patients. We searched major databases for randomized controlled trials and observational studies comparing outcomes between hypercapnia and normocapnia in adult post-cardiac arrest patients. Data on in-hospital mortality and the ICU and hospital length of stay were extracted and pooled using random-effects meta-analysis. Five studies (two randomized controlled trials (RCTs) and three observational studies) with a total of 1,837 patients were included. Pooled analysis showed hypercapnia was associated with significantly higher in-hospital mortality compared to normocapnia (56.2% vs. 50.5%, OR 1.24, 95% CI 1.12-1.37, p<0.001). There was no significant heterogeneity (I2 = 25%, p = 0.26). No statistically significant differences were found for ICU length of stay (mean difference 0.72 days, 95% CI -0.51 to 1.95) or hospital length of stay (mean difference 1.13 days, 95% CI -0.67 to 2.93) between the groups. Sensitivity analysis restricted to mild hypercapnia studies did not alter the mortality findings. This meta-analysis did not find a mortality benefit with targeted hypercapnia compared to normocapnia in post-cardiac arrest patients. The results align with current guidelines recommending a normal partial pressure of arterial carbon dioxide (PaCO2) target range and do not support routinely targeting higher carbon dioxide levels in this setting.
Collapse
Affiliation(s)
| | - Tanya Sinha
- Medicine, Tribhuvan University, Kathmandu, NPL
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Thin M Soe
- Medicine, University of Medicine 1, Yangon, MMR
| | - Ghazala Munawar
- Internal Medicine, Northwest General Hospital and Research Center, Peshawar, PAK
| | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
| | - Neelum Ali
- Internal Medicine, University of Health Sciences, Lahore, PAK
| |
Collapse
|
4
|
Campaña-Duel E, Ceccato A, Morales-Quinteros L, Camprubí-Rimblas M, Artigas A. Hypercapnia and its relationship with respiratory infections. Expert Rev Respir Med 2024; 18:41-47. [PMID: 38489161 DOI: 10.1080/17476348.2024.2331767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/13/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Hypercapnia is developed in patients with acute and/or chronic respiratory conditions. Clinical data concerning hypercapnia and respiratory infections interaction is limited. AREAS COVERED Currently, the relationship between hypercapnia and respiratory infections remains unclear. In this review, we summarize studies on the effects of hypercapnia on models of pulmonary infections to clarify the role of elevated CO2 in these pulmonary pathologies. Hypercapnia affects different cell types in the alveoli, leading to changes in the immune response. In vitro studies show that hypercapnia downregulates the NF-κβ pathway, reduces inflammation and impairs epithelial wound healing. While in vivo models show a dual role between short- and long-term effects of hypercapnia on lung infection. However, it is still controversial whether the effects observed under hypercapnia are pH dependent or not. EXPERT OPINION The role of hypercapnia is still a controversial debate. Hypercapnia could play a beneficial role in mechanically ventilated models, by lowering the inflammation produced by the stretch condition. But it could be detrimental in infectious scenarios, causing phagocyte dysfunction and lack of infection control. Further data concerning hypercapnia on respiratory infections is needed to elucidate this interaction.
Collapse
Affiliation(s)
- Elena Campaña-Duel
- Critical care center, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | - Adrian Ceccato
- Critical care center, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Intensive care unit, Hospital Universitari Sagrat Cor, Grupo Quironsalud, Barcelona, Spain
| | - Luis Morales-Quinteros
- Critical care center, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Servei de Medicina Intensiva, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Marta Camprubí-Rimblas
- Critical care center, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | - Antonio Artigas
- Critical care center, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| |
Collapse
|
5
|
Yetiskul E, Lisle S, Rizvi TA, Khan S, Maniatis GA. Oxygen Overshoot: A Case Report Navigating the Perils of Unsupervised Supplementation in Chronic Obstructive Pulmonary Disease (COPD). Cureus 2023; 15:e50274. [PMID: 38196421 PMCID: PMC10775892 DOI: 10.7759/cureus.50274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 01/11/2024] Open
Abstract
Supplemental oxygen administration is a delicate balance in managing chronic obstructive pulmonary disease (COPD), where the risk of exacerbating hypercapnia must be carefully considered. This case report describes a 69-year-old male with COPD who, after self-medicating with commercially available portable oxygen bottles, experienced hypercapnic respiratory failure and severe respiratory acidosis, leading to intensive care unit (ICU) admission and non-invasive ventilation. The patient's unsupervised use of commercially available portable oxygen bottles emphasizes the risks associated with unregulated supplemental oxygen in COPD. This case highlights the critical importance of cautious oxygen supplementation in COPD, urging high-risk patients to seek medical guidance, even with over-the-counter products. This case emphasizes the need for expert medical opinion to ensure safe oxygen use in vulnerable populations.
Collapse
Affiliation(s)
- Ekrem Yetiskul
- Internal Medicine, Staten Island University Hospital-Northwell Health, New York, USA
| | - Seth Lisle
- Internal Medicine, Touro College of Osteopathic Medicine, New York, USA
| | - Taqi A Rizvi
- Internal Medicine, Staten Island University Hospital-Northwell Health, New York, USA
| | - Shahkar Khan
- Internal Medicine, Staten Island University Hospital-Northwell Health, New York, USA
| | - Gregory A Maniatis
- Cardiology, Staten Island University Hospital-Northwell Health, New York, USA
| |
Collapse
|
6
|
Melberg MB, Flaa A, Andersen GØ, Sunde K, Bellomo R, Eastwood G, Olasveengen TM, Qvigstad E. Cardiovascular changes induced by targeted mild hypercapnia after out of hospital cardiac arrest. A sub-study of the TAME cardiac arrest trial. Resuscitation 2023; 193:109970. [PMID: 37716401 DOI: 10.1016/j.resuscitation.2023.109970] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023]
Abstract
AIM Hypercapnia may elicit detrimental haemodynamic effects in critically ill patients. We aimed to investigate the consequences of targeted mild hypercapnia versus targeted normocapnia on pulmonary vascular resistance and right ventricular function in patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS Pre-planned, single-centre, prospective, sub-study of the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. Patients were randomised to mild hypercapnia (PaCO2 = 6.7-7.3 kPa) or normocapnia (PaCO2 = 4.7-6.0 kPa) for 24 hours. Haemodynamic assessment was performed with right heart catheterisation and serial blood-gas analyses every4th hour for 48 hours. RESULTS We studied 84 patients. Mean pH was 7.24 (95% CI 7.22-7.30) and 7.32 (95% CI 7.31-7.34) with hypercapnia and normocapnia, respectively (P-group < 0.001). Pulmonary vascular resistance index (PVRI), pulmonary artery pulsatility index, and right atrial pressure did not differ between groups (P-group > 0.05). Mean cardiac index was higher with mild hypercapnia (P-group < 0.001): 2.0 (95% CI 1.85-2.1) vs 1.6 (95% CI 1.52-1.76) L/min/m2. Systemic vascular resistance index was 2579 dyne-sec/cm-5/ m2 (95% CI 2356-2830) with hypercapnia, and 3249 dyne-sec/cm-5/ m2 (95% CI 2930-3368) with normocapnia (P-group < 0.001). Stroke volumes (P-group = 0.013) and mixed venous oxygen saturation (P-group < 0.001) were higher in the hypercapnic group. CONCLUSION In resuscitated OHCA patients, targeting mild hypercapnia did not increase PVRI or worsen right ventricular function compared to normocapnia. Mild hypercapnia comparatively improved cardiac performance and mixed venous oxygen saturation.
Collapse
Affiliation(s)
- Mathias Baumann Melberg
- Department of Research and Development, Division of Emergencies and Critical Care, Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway.
| | - Arnljot Flaa
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Øystein Andersen
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Department of Anaesthesiology and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; Department of Critical Care, Melbourne University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Theresa Mariero Olasveengen
- Department of Anaesthesiology and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Eirik Qvigstad
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
7
|
Fenton NM, Brown AJ. A tale of 2 gasses, 1 regulator, and cholesterol homeostasis. PLoS Biol 2023; 21:e3002401. [PMID: 37992072 PMCID: PMC10664885 DOI: 10.1371/journal.pbio.3002401] [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: 11/24/2023] Open
Abstract
There is a burgeoning appreciation for the wide-ranging effects of carbon dioxide on transcriptional regulation and metabolism. Here, Bolshette and colleagues provide the first link between carbon dioxide and the master transcriptional regulator of cholesterol homeostasis.
Collapse
Affiliation(s)
- Nicole M. Fenton
- School of Biotechnology and Biomolecular Sciences, UNSW Sydney, Sydney, Australia
| | - Andrew J. Brown
- School of Biotechnology and Biomolecular Sciences, UNSW Sydney, Sydney, Australia
| |
Collapse
|
8
|
Zhou D, Lv Y, Lin Q, Wang C, Fei S, He W. Association between rate of change in PaCO 2 and functional outcome for patients with hypercapnia after out-of-hospital cardiac arrest: Secondary analysis of a randomized clinical trial. Am J Emerg Med 2023; 65:139-145. [PMID: 36634567 DOI: 10.1016/j.ajem.2023.01.004] [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: 09/27/2022] [Revised: 12/10/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Normocapnia is suggested for post resuscitation care. For patients with hypercapnia after cardiac arrest, the relationship between rate of change in partial pressure of carbon dioxide (PaCO2) and functional outcome was unknown. METHODS This was the secondary analysis of Resuscitation Outcomes Consortium (ROC) amiodarone, lidocaine, and placebo (ALPS) trial. Patients with at least 2 PaCO2 recorded and the first indicating hypercapnia (PaCO2 > 45 mmHg) after return of spontaneous circulation (ROSC) were included. The rate of change in PaCO2 was calculated as the ratio of the difference between the second and first PaCO2 to the time interval. The primary outcome was modified Rankin Score (mRS), dichotomized to good (mRS 0-3) and poor (mRS 4-6) outcomes at hospital discharge. The independent relationship between rate of change in PaCO2 and outcome was investigated with multivariable logistic regression model. RESULTS A total of 746 patients with hypercapnia were included for analysis, of which 264 (35.4%) patients had good functional outcome. The median rate of change in PaCO2 was 4.7 (interquartile range [IQR] 1.7-12) mmHg per hour. After adjusting for confounders, the rate of change in PaCO2 (odds ratio [OR] 0.994, confidence interval [CI] 0.985-1.004, p = 0.230) was not associated the functional outcome. However, rate of change in PaCO2 (OR 1.010, CI 1.001-1.019, p = 0.029) was independently associated with hospital mortality. CONCLUSIONS For OHCA patients with hypercapnia on admission, the rate of change in PaCO2 was not independently associated with functional outcome; however, there was a significant trend that higher decreased rate was associated with increased hospital mortality.
Collapse
Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| | - Yi Lv
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qing Lin
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shuyang Fei
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wei He
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
Pape P, Piosik ZM, Kristensen CM, Dirks J, Rasmussen LS, Kristensen MS. Transcutaneous carbon dioxide monitoring during prolonged apnoea with high-flow nasal oxygen. Acta Anaesthesiol Scand 2023; 67:649-654. [PMID: 36760034 DOI: 10.1111/aas.14216] [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: 11/04/2022] [Revised: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The duration of apnoeic oxygenation with high-flow nasal oxygen is limited by hypercapnia and acidosis and monitoring of arterial carbon dioxide level is therefore essential. We have performed a study in patients undergoing prolonged apnoeic oxygenation where we monitored the progressive hypercapnia with transcutaneous carbon dioxide. In this paper, we compared the transcutaneous carbon dioxide level with arterial carbon dioxide tension. METHODS This is a secondary publication based on data from a study exploring the limits of apnoeic oxygenation. We compared transcutaneous carbon dioxide monitoring with arterial carbon dioxide tension using Bland-Altman analyses in anaesthetised and paralysed patients undergoing prolonged apnoeic oxygenation until a predefined limit of pH 7.15 or PCO2 of 12 kPa was reached. RESULTS We included 35 patients with a median apnoea duration of 25 min. Mean pH was 7.14 and mean arterial carbon dioxide tension was 11.2 kPa at the termination of apnoeic oxygenation. Transcutaneous carbon dioxide monitoring initially slightly underestimated the arterial tension but at carbon dioxide levels above 10 kPa it overestimated the value. Bias ranged from -0.55 to 0.81 kPa with limits of agreement between -1.25 and 2.11 kPa. CONCLUSION Transcutaneous carbon dioxide monitoring provided a clinically acceptable substitute for arterial blood gases but as hypercapnia developed to considerable levels, we observed overestimation at high carbon dioxide tensions in patients undergoing apnoeic oxygenation with high-flow nasal oxygen.
Collapse
Affiliation(s)
- Pernille Pape
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Zofia M Piosik
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Nordsjaellands Hospital, Hilleroed, Denmark
| | - Camilla M Kristensen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Dirks
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael S Kristensen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
10
|
Tang WJ, Xie BK, Liang W, Zhou YZ, Kuang WL, Chen F, Wang M, Yu M. Hypocapnia is an independent predictor of in-hospital mortality in acute heart failure. ESC Heart Fail 2023; 10:1385-1400. [PMID: 36747311 PMCID: PMC10053155 DOI: 10.1002/ehf2.14306] [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: 05/11/2022] [Revised: 12/13/2022] [Accepted: 01/16/2023] [Indexed: 02/08/2023] Open
Abstract
AIMS Acute heart failure (AHF) poses a major threat to hospitalized patients for its high mortality rate and serious complications. The aim of this study is to determine whether hypocapnia [defined as the partial pressure of arterial carbon dioxide (PaCO2 ) below 35 mmHg] on admission could be associated with in-hospital all-cause mortality in AHF. METHODS AND RESULTS A total of 676 patients treated in the coronary care unit for AHF were retrospectively analysed, and the study endpoint was in-hospital all-cause mortality. The 1:1 propensity score matching (PSM) analysis, Kaplan-Meier curve, and Cox regression model were used to explore the association between hypocapnia and in-hospital all-cause mortality in AHF. Receiver operating characteristic (ROC) curve and Delong's test were used to assess the performance of hypocapnia in predicting in-hospital all-cause mortality in AHF. The study cohort included 464 (68.6%) males and 212 (31.4%) females, and the median age was 66 years (interquartile range 56-74 years). Ninety-eight (14.5%) patients died during hospitalization and presented more hypocapnia than survivors (76.5% vs. 45.5%, P < 0.001). A 1:1 PSM was performed between hypocapnic and non-hypocapnic patients, with 264 individuals in each of the two groups after matching. Compared with non-hypocapnic patients, in-hospital mortality was significantly higher in hypocapnic patients both before (22.2% vs. 6.8%, P < 0.001) and after (20.8% vs. 8.7%, P < 0.001) PSM. Kaplan-Meier curve showed a significantly higher probability of in-hospital death in patients with hypocapnia before and after PSM (both P < 0.001 for the log-rank test). Multivariate Cox regression analysis showed that hypocapnia was an independent predictor of AHF mortality both before [hazard ratio (HR) 2.22; 95% confidence interval (CI) 1.23-3.98; P = 0.008] and after (HR 2.19; 95% CI 1.18-4.07; P = 0.013) PSM. Delong's test showed that the area under the ROC curve was improved after adding hypocapnia into the model (0.872, 95% CI 0.839-0.901 vs. 0.855, 95% CI 0.820-0.886, P = 0.028). PaCO2 was correlated with the estimated glomerular filtration rate (r = 0.20, P = 0.001), left ventricular ejection fraction (r = 0.13, P < 0.001), B-type natriuretic peptide (r = -0.28, P < 0.001), and lactate (r = -0.15, P < 0.001). Kaplan-Meier curve of PaCO2 tertiles and multivariate Cox regression analysis showed that the lowest PaCO2 tertile was associated with increased risk of in-hospital mortality in AHF (all P < 0.05). CONCLUSIONS Hypocapnia is an independent predictor of in-hospital mortality for AHF.
Collapse
Affiliation(s)
- Wen-Jing Tang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Bai-Kang Xie
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Wei Liang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Yan-Zhao Zhou
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Wen-Long Kuang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Fen Chen
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Min Wang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Miao Yu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| |
Collapse
|
11
|
Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation. ASAIO J 2022; 69:411-416. [PMID: 36730940 PMCID: PMC10044589 DOI: 10.1097/mat.0000000000001838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The primary objective was to investigate the association between partial pressure of carbon dioxide (PaCO2) change after extracorporeal membrane oxygenation (ECMO) initiation and neurologic outcome in neonates treated for respiratory failure. A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database including newborns supported by ECMO for respiratory indication during 2015-2020. The closest Pre-ECMO (Pre-ECMO PaCO2) and at 24 hours after ECMO initiation (H24 PaCO2) PaCO2 values allowed to calculate the relative change in PaCO2 (Rel Δ PaCO2 = [H24 PaCO2 - Pre-ECMO PaCO2]/Pre-ECMO PaCO2). The primary outcome was the onset of any acute neurologic event (ANE), defined as cerebral bleeding, ischemic stroke, clinical or electrical seizure, or brain death during ECMO. We included 3,583 newborns (median age 1 day [interquartile range {IQR}, 1-3], median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers. The median Rel Δ PaCO2 value was -29.9% [IQR, -46.2 to -8.5]. Six hundred nine (17%) of them had ANE (405 cerebral bleedings, 111 ischemic strokes, 225 seizures, and 6 brain deaths). Patients with a decrease of PaCO2 > 50% were more likely to develop ANE than others (odds ratio [OR] 1.78, 95% confidence interval [CI], 1.31-2.42, p < 0.001). This was still observed after adjustment for all clinically relevant confounding factors (adjusted OR 1.94, 95% CI, 1.29-2.92, p = 0.001). A significant decrease in PaCO2 after ECMO start is associated with ANE among neonates requiring ECMO for respiratory failure. Cautious PaCO2 decrease should be considered after start of ECMO therapy.
Collapse
|
12
|
Csoma B, Vulpi MR, Dragonieri S, Bentley A, Felton T, Lázár Z, Bikov A. Hypercapnia in COPD: Causes, Consequences, and Therapy. J Clin Med 2022; 11:jcm11113180. [PMID: 35683563 PMCID: PMC9181664 DOI: 10.3390/jcm11113180] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/28/2022] [Accepted: 05/31/2022] [Indexed: 12/18/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder that may lead to gas exchange abnormalities, including hypercapnia. Chronic hypercapnia is an independent risk factor of mortality in COPD, leading to epithelial dysfunction and impaired lung immunity. Moreover, chronic hypercapnia affects the cardiovascular physiology, increases the risk of cardiovascular morbidity and mortality, and promotes muscle wasting and musculoskeletal abnormalities. Noninvasive ventilation is a widely used technique to remove carbon dioxide, and several studies have investigated its role in COPD. In the present review, we aim to summarize the causes and effects of chronic hypercapnia in COPD. Furthermore, we discuss the use of domiciliary noninvasive ventilation as a treatment option for hypercapnia while highlighting the controversies within the evidence. Finally, we provide some insightful clinical recommendations and draw attention to possible future research areas.
Collapse
Affiliation(s)
- Balázs Csoma
- Department of Pulmonology, Semmelweis University, 25-29 Tömő Str., 1083 Budapest, Hungary; (B.C.); (Z.L.)
| | - Maria Rosaria Vulpi
- School of Medicine: Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, 11 Piazza G. Cesare-Bari, 70124 Bari, Italy; (M.R.V.); (S.D.)
| | - Silvano Dragonieri
- School of Medicine: Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, 11 Piazza G. Cesare-Bari, 70124 Bari, Italy; (M.R.V.); (S.D.)
| | - Andrew Bentley
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, UK; (A.B.); (T.F.)
| | - Timothy Felton
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, UK; (A.B.); (T.F.)
| | - Zsófia Lázár
- Department of Pulmonology, Semmelweis University, 25-29 Tömő Str., 1083 Budapest, Hungary; (B.C.); (Z.L.)
| | - Andras Bikov
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, UK; (A.B.); (T.F.)
- Correspondence: ; Tel.: +36-203141599
| |
Collapse
|
13
|
Affiliation(s)
- Philip Fortuna
- Centro Hospitalar Universitário de Lisboa Central EPE, Lisbon, Portugal.
| | - Simão Rodeia
- Centro Hospitalar Universitário de Lisboa Central EPE, Lisbon, Portugal
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental EPE, Lisbon, Portugal
| |
Collapse
|
14
|
Hof S, Truse R, Weber L, Herminghaus A, Schulz J, Weber APM, Maleckova E, Bauer I, Picker O, Vollmer C. Local Mucosal CO 2 but Not O 2 Insufflation Improves Gastric and Oral Microcirculatory Oxygenation in a Canine Model of Mild Hemorrhagic Shock. Front Med (Lausanne) 2022; 9:867298. [PMID: 35573010 PMCID: PMC9096873 DOI: 10.3389/fmed.2022.867298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Acute hemorrhage results in perfusion deficit and regional hypoxia. Since failure of intestinal integrity seem to be the linking element between hemorrhage, delayed multi organ failure, and mortality, it is crucial to maintain intestinal microcirculation in acute hemorrhage. During critical bleeding physicians increase FiO2 to raise total blood oxygen content. Likewise, a systemic hypercapnia was reported to maintain microvascular oxygenation (μHbO2). Both, O2 and CO2, may have adverse effects when applied systemically that might be prevented by local application. Therefore, we investigated the effects of local hyperoxia and hypercapnia on the gastric and oral microcirculation. Methods Six female foxhounds were anaesthetized, randomized into eight groups and tested in a cross-over design. The dogs received a local CO2-, O2-, or N2-administration to their oral and gastric mucosa. Hemorrhagic shock was induced through a withdrawal of 20% of estimated blood volume followed by retransfusion 60 min later. In control groups no shock was induced. Reflectance spectrophotometry and laser Doppler were performed at the gastric and oral surface. Oral microcirculation was visualized by incident dark field imaging. Systemic hemodynamic parameters were recorded continuously. Statistics were performed using a two-way-ANOVA for repeated measurements and post hoc analysis was conducted by Bonferroni testing (p < 0.05). Results The gastric μHbO2 decreased from 76 ± 3% to 38 ± 4% during hemorrhage in normocapnic animals. Local hypercapnia ameliorated the decrease of μHbO2 from 78 ± 4% to 51 ± 8%. Similarly, the oral μHbO2 decreased from 81 ± 1% to 36 ± 4% under hemorrhagic conditions and was diminished by local hypercapnia (54 ± 4%). The oral microvascular flow quality but not the total microvascular blood flow was significantly improved by local hypercapnia. Local O2-application failed to change microvascular oxygenation, perfusion or flow quality. Neither CO2 nor O2 changed microcirculatory parameters and macrocirculatory hemodynamics under physiological conditions. Discussion Local hypercapnia improved microvascular oxygenation and was associated with a continuous blood flow in hypercapnic individuals undergoing hemorrhagic shock. Local O2 application did not change microvascular oxygenation, perfusion and blood flow profiles in hemorrhage. Local gas application and change of microcirculation has no side effects on macrocirculatory parameters.
Collapse
Affiliation(s)
- Stefan Hof
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Richard Truse
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Lea Weber
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Jan Schulz
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Andreas P M Weber
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Eva Maleckova
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| |
Collapse
|
15
|
Triantaris A, Aidonidis I, Hatziefthimiou A, Gourgoulianis K, Zakynthinos G, Makris D. Elevated PaCO 2 levels increase pulmonary artery pressure. Sci Prog 2022; 105:368504221094161. [PMID: 35440248 PMCID: PMC10358613 DOI: 10.1177/00368504221094161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Permissive hypercapnia is commonly used in mechanically ventilated patients to avoid lung injury but its effect on pulmonary artery pressure (PAP) is still unclear, particularly in combination with tidal volume (Vt). Therefore, an in vivo study was performed on adult rabbits ventilated with low (9 ml/Kg, LVt group) or high (15 ml/Kg, HVt group) tidal volume (Vt) and alterations in PAP were estimated. Both groups of animals initially were ventilated with FiO2 0.3 (Normocapnia-1) followed by inhalation of enriched CO2 gas mixture (FiCO2 0.10) to develop hypercapnia (Hypercapnia-1). After 30 min of hypercapnia, animals were re-ventilated with FiO2 0.3 to develop normocapnia (Normocapnia-2) again and then with FiCO2 0.10 to develop hypercapnia (Hypercapnia-2). Systolic, diastolic and mean PAP were assessed with a catheter in the pulmonary artery. In HP-1 and HP-2, PaCO2 increased (p < 0.0001) in both LVt and HVt animals compared to baseline values. pH decreased to ≈7.2 in HP-1 and ≈7.1 in HP -2. In normocapnia, the rise in Vt from 9 to 15 ml/Kg induced an increase in static compliance (Cstat), plateau airway pressure (Pplat) and PAP. Hypercapnia increased PAP in either LVt or HVt animals without significant effect on Cstat or Pplat. A two-way ANOVA revealed that there was not a statistically significant interaction between the effects of hypercapnia and tidal volume on mPAP (p = 0.76). In conclusion, increased Vt per se induced an increase in Cstat, Pplat and PAP in normocapnia. Hypercapnia increased PAP in rabbits ventilated with low or high Vt but this effect was not long-lasting.
Collapse
Affiliation(s)
- Apostolos Triantaris
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Isaak Aidonidis
- Laboratory of Physiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Apostolia Hatziefthimiou
- Laboratory of Physiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Gourgoulianis
- Department of Respiratory Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Georgios Zakynthinos
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Demosthenes Makris
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
16
|
|
17
|
Tiruvoipati R, Serpa Neto A, Young M, Marhoon N, Wilson J, Gupta S, Pilcher D, Bailey M, Bellomo R. An Exploratory Analysis of the Association between Hypercapnia and Hospital Mortality in Critically Ill Patients with Sepsis. Ann Am Thorac Soc 2022; 19:245-254. [PMID: 34380007 DOI: 10.1513/annalsats.202102-104oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Rationale: Hypercapnia may affect the outcome of sepsis. Very few clinical studies conducted in noncritically ill patients have investigated the effects of hypercapnia and hypercapnic acidemia in the context of sepsis. The effect of hypercapnia in critically ill patients with sepsis remains inadequately studied. Objectives: To investigate the association of hypercapnia with hospital mortality in critically ill patients with sepsis. Methods: This is a retrospective study conducted in three tertiary public hospitals. Critically ill patients with sepsis from three intensive care units between January 2011 and May 2019 were included. Five cohorts (exposure of at least 24, 48, 72, 120, and 168 hours) were created to account for immortal time bias and informative censoring. The association between hypercapnia exposure and hospital mortality was assessed with multivariable models. Subgroup analyses compared ventilated versus nonventilated and pulmonary versus nonpulmonary sepsis patients. Results: We analyzed 84,819 arterial carbon dioxide pressure measurements in 3,153 patients (57.6% male; median age was 62.5 years). After adjustment for key confounders, both in mechanically ventilated and nonventilated patients and in patients with pulmonary or nonpulmonary sepsis, there was no independent association of hypercapnia with hospital mortality. In contrast, in ventilated patients, the presence of prolonged exposure to both hypercapnia and acidemia was associated with increased mortality (highest odds ratio of 16.5 for ⩾120 hours of potential exposure; P = 0.007). Conclusions: After adjustment, isolated hypercapnia was not associated with increased mortality in patients with sepsis, whereas prolonged hypercapnic acidemia was associated with increased risk of mortality. These hypothesis-generating observations suggest that as hypercapnia is not an independent risk factor for mortality, trials of permissive hypercapnia avoiding or minimizing acidemia in sepsis may be safe.
Collapse
Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Marcus Young
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Nada Marhoon
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - John Wilson
- Peninsula Health Informatics, Frankston Hospital, Melbourne, Victoria, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia; and
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation, the University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Data Analytics Research and Evaluation, the University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
18
|
Dervieux E, Théron M, Uhring W. Carbon Dioxide Sensing-Biomedical Applications to Human Subjects. SENSORS (BASEL, SWITZERLAND) 2021; 22:188. [PMID: 35009731 PMCID: PMC8749784 DOI: 10.3390/s22010188] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/13/2021] [Accepted: 12/20/2021] [Indexed: 02/06/2023]
Abstract
Carbon dioxide (CO2) monitoring in human subjects is of crucial importance in medical practice. Transcutaneous monitors based on the Stow-Severinghaus electrode make a good alternative to the painful and risky arterial "blood gases" sampling. Yet, such monitors are not only expensive, but also bulky and continuously drifting, requiring frequent recalibrations by trained medical staff. Aiming at finding alternatives, the full panel of CO2 measurement techniques is thoroughly reviewed. The physicochemical working principle of each sensing technique is given, as well as some typical merit criteria, advantages, and drawbacks. An overview of the main CO2 monitoring methods and sites routinely used in clinical practice is also provided, revealing their constraints and specificities. The reviewed CO2 sensing techniques are then evaluated in view of the latter clinical constraints and transcutaneous sensing coupled to a dye-based fluorescence CO2 sensing seems to offer the best potential for the development of a future non-invasive clinical CO2 monitor.
Collapse
Affiliation(s)
- Emmanuel Dervieux
- BiOSENCY, 1137a Avenue des Champs Blancs, 35510 Cesson-Sévigné, France
| | - Michaël Théron
- ORPHY, Université de Bretagne Occidentale, 6 Avenue Victor le Gorgeu, 29238 Brest, France;
| | - Wilfried Uhring
- ICube, University of Strasbourg and CNRS, 23 rue du Loess, CEDEX, 67037 Strasbourg, France;
| |
Collapse
|
19
|
Forsberg I, Mkrtchian S, Ebberyd A, Ullman J, Eriksson LI, Lodenius Å, Jonsson Fagerlund M. Biomarkers for oxidative stress and organ injury during Transnasal Humidified Rapid-Insufflation Ventilatory Exchange compared to mechanical ventilation in adults undergoing microlaryngoscopy: A randomised controlled study. Acta Anaesthesiol Scand 2021; 65:1276-1284. [PMID: 34028012 DOI: 10.1111/aas.13927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Apnoeic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) during general anaesthesia prolongs the safe apnoeic period. However, there is a gap of knowledge how THRIVE-induced hyperoxia and hypercapnia impact vital organs. The primary aim of this randomised controlled trial was to characterise oxidative stress and, secondary, vital organ function biomarkers during THRIVE compared to mechanical ventilation (MV). METHODS Thirty adult patients, American Society of Anesthesiologists (ASA) 1-2, undergoing short laryngeal surgery under general anaesthesia were randomised to THRIVE, FI O2 1.0, 70 L min-1 during apnoea or MV. Blood biomarkers for oxidative stress, malondialdehyde and TAC and vital organ function were collected (A) preoperatively, (B) at procedure completion and (C) at PACU discharge. RESULTS Mean apnoea time was 17.9 (4.8) min and intubation to end-of-surgery time was 28.1 (12.8) min in the THRIVE and MV group, respectively. Malondialdehyde increased from 11.2 (3.1) to 12.7 (3.1) µM (P = .02) and from 9.5 (2.2) to 11.6 (2.6) µM (P = .003) (A to C) in the THRIVE and MV group, respectively. S100B increased from 0.05 (0.02) to 0.06 (0.02) µg L-1 (P = .005) (A to C) in the THRIVE group. No increase in TAC, CRP, leukocyte count, troponin-T, NTproBNP, creatinine, eGFRcrea or NSE was demonstrated during THRIVE. CONCLUSION While THRIVE and MV was associated with increased oxidative stress, we found no change in cardiac, inflammation or kidney biomarkers during THRIVE. Further evaluation of stress and inflammatory response and cerebral and cardiac function during THRIVE is needed.
Collapse
Affiliation(s)
- Ida‐Maria Forsberg
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Souren Mkrtchian
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Anette Ebberyd
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Johan Ullman
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Lars I. Eriksson
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Åse Lodenius
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet Stockholm Sweden
| |
Collapse
|
20
|
Ding X, Chen H, Zhao H, Zhang H, He H, Cheng W, Wang C, Jiang W, Ma J, Qin Y, Liu Z, Wang J, Yan X, Li T, Zhou X, Long Y, Zhang S. ECCO 2R in 12 COVID-19 ARDS Patients With Extremely Low Compliance and Refractory Hypercapnia. Front Med (Lausanne) 2021; 8:654658. [PMID: 34307397 PMCID: PMC8295461 DOI: 10.3389/fmed.2021.654658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: A phenotype of COVID-19 ARDS patients with extremely low compliance and refractory hypercapnia was found in our ICU. In the context of limited number of ECMO machines, feasibility of a low-flow extracorporeal carbon dioxide removal (ECCO2R) based on the renal replacement therapy (RRT) platform in these patients was assessed. Methods: Single-center, prospective study. Refractory hypercapnia patients with COVID-19-associated ARDS were included and divided into the adjusted group and unadjusted group according to the level of PaCO2 after the application of the ECCO2R system. Ventilation parameters [tidal volume (VT), respiratory rate, and PEEP], platform pressure (Pplat) and driving pressure (DP), respiratory system compliance, arterial blood gases, and ECCO2R system characteristics were collected. Results: Twelve patients with refractory hypercapnia were enrolled, and the PaCO2 was 64.5 [56-88.75] mmHg. In the adjusted group, VT was significantly reduced from 5.90 ± 0.16 to 5.08 ± 0.43 ml/kg PBW; DP and Pplat were also significantly reduced from 23.5 ± 2.72 mmHg and 29.88 ± 3.04 mmHg to 18.5 ± 2.62 mmHg and 24.75 ± 3.41 mmHg, respectively. In the unadjusted group, PaCO2 decreased from 94 [86.25, 100.3] mmHg to 80 [67.50, 85.25] mmHg but with no significant difference, and the DP and Pplat were not decreased after weighing the pros and cons. Conclusions: A low-flow ECCO2R system based on the RRT platform enabled CO2 removal and could also decrease the DP and Pplat significantly, which provided a new way to treat these COVID-19 ARDS patients with refractory hypercapnia and extremely low compliance. Clinical Trial Registration: https://www.clinicaltrials.gov/, identifier NCT04340414.
Collapse
Affiliation(s)
- Xin Ding
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huan Chen
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hua Zhao
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Cheng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chunyao Wang
- Department of Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Jiang
- Department of Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jie Ma
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yan Qin
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhengyin Liu
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinglan Wang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaowei Yan
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Taisheng Li
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shuyang Zhang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| |
Collapse
|
21
|
Frérou A, Maamar A, Rafi S, Lhommet C, Phelouzat P, Pontis E, Reizine F, Lesouhaitier M, Camus C, Le Tulzo Y, Tadié JM, Gacouin A. Monitoring Transcutaneously Measured Partial Pressure of CO 2 During Intubation in Critically Ill Subjects. Respir Care 2021; 66:1004-1015. [PMID: 33824171 DOI: 10.4187/respcare.08009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The risk for severe hypoxemia during endotracheal intubation is a major concern in the ICU, but little attention has been paid to CO2 variability. The objective of this study was to assess transcutaneously measured partial pressure of CO2 ([Formula: see text]) throughout intubation in subjects in the ICU who received standard oxygen therapy, high-flow nasal cannula oxygen therapy, or noninvasive ventilation for preoxygenation. We hypothesized that the 3 methods differ in terms of ventilation and CO2 removal. METHODS In this single-center, prospective, observational study, we recorded [Formula: see text] from preoxygenation to 3 h after the initiation of mechanical ventilation among subjects requiring endotracheal intubation. Subjects were sorted into 3 groups according to the preoxygenation method. We then assessed the link between [Formula: see text] variability and the development of postintubation hypotension. RESULTS A total of 202 subjects were included in the study. The [Formula: see text] values recorded at endotracheal intubation, at the initiation of mechanical ventilation, and after 30 min and 1 h of mechanical ventilation were significantly higher than those recorded during preoxygenation (P < .05). [Formula: see text] variability differed significantly according to the preoxygenation method (P < .001, linear mixed model). A decrease in [Formula: see text] by > 5 mm Hg within 30 min after the start of mechanical ventilation was independently associated with postintubation hypotension (odds ratio = 2.14 [95% CI 1.03-4.44], P = .039) after adjustments for age, Simplified Acute Physiology Score II, COPD, cardiac comorbidity, the use of propofol for anesthetic induction, and minute ventilation at the start of mechanical ventilation. CONCLUSIONS [Formula: see text] variability during intubation is significant and differs with the method of preoxygenation. A decrease in [Formula: see text] after the beginning of mechanical ventilation was associated with postintubation hypotension. (ClinicalTrials.gov registration NCT0388430.).
Collapse
Affiliation(s)
- Aurélien Frérou
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Adel Maamar
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Sonia Rafi
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Claire Lhommet
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Pierre Phelouzat
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Emmanuel Pontis
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Florian Reizine
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Mathieu Lesouhaitier
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Christophe Camus
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Yves Le Tulzo
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Jean-Marc Tadié
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Arnaud Gacouin
- Service de Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| |
Collapse
|
22
|
Association Between Arterial Carbon Dioxide Tension and Clinical Outcomes in Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:977-984. [PMID: 32574466 DOI: 10.1097/ccm.0000000000004347] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The manipulation of arterial carbon dioxide tension is associated with differential mortality and neurologic injury in intensive care and cardiac arrest patients; however, few studies have investigated this relationship in patients on venoarterial extracorporeal membrane oxygenation. We investigated the association between the initial arterial carbon dioxide tension and change over 24 hours on mortality and neurologic injury in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiac arrest and refractory cardiogenic shock. DESIGN Retrospective cohort analysis of adult patients recorded in the international Extracorporeal Life Support Organization Registry. SETTING Data reported to the Extracorporeal Life Support Organization from all international extracorporeal membrane oxygenation centers during 2003-2016. PATIENTS Adult patients (≥ 18 yr old) supported with venoarterial extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 7,168 patients had sufficient data for analysis at the initiation of venoarterial extracorporeal membrane oxygenation, 4,918 of these patients had arterial carbon dioxide tension data available at 24 hours on support. The overall in-hospital mortality rate was 59.9%. A U-shaped relationship between arterial carbon dioxide tension tension at extracorporeal membrane oxygenation initiation and in-hospital mortality was observed. Increased mortality was observed with a arterial carbon dioxide tension less than 30 mm Hg (odds ratio, 1.26; 95% CI, 1.08-1.47; p = 0.003) and greater than 60 mm Hg (odds ratio, 1.28; 95% CI, 1.10-1.50; p = 0.002). Large reductions (> 20 mm Hg) in arterial carbon dioxide tension over 24 hours were associated with important neurologic complications: intracranial hemorrhage, ischemic stroke, and/or brain death, as a composite outcome (odds ratio, 1.63; 95% CI, 1.03-2.59; p = 0.04), independent of the initial arterial carbon dioxide tension. CONCLUSIONS Initial arterial carbon dioxide tension tension was independently associated with mortality in this cohort of venoarterial extracorporeal membrane oxygenation patients. Reductions in arterial carbon dioxide tension (> 20 mm Hg) from the initiation of extracorporeal membrane oxygenation were associated with neurologic complications. Further prospective studies testing these associations are warranted.
Collapse
|
23
|
Phelan DE, Mota C, Lai C, Kierans SJ, Cummins EP. Carbon dioxide-dependent signal transduction in mammalian systems. Interface Focus 2021; 11:20200033. [PMID: 33633832 PMCID: PMC7898142 DOI: 10.1098/rsfs.2020.0033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/15/2022] Open
Abstract
Carbon dioxide (CO2) is a fundamental physiological gas known to profoundly influence the behaviour and health of millions of species within the plant and animal kingdoms in particular. A recent Royal Society meeting on the topic of 'Carbon dioxide detection in biological systems' was extremely revealing in terms of the multitude of roles that different levels of CO2 play in influencing plants and animals alike. While outstanding research has been performed by leading researchers in the area of plant biology, neuronal sensing, cell signalling, gas transport, inflammation, lung function and clinical medicine, there is still much to be learned about CO2-dependent sensing and signalling. Notably, while several key signal transduction pathways and nodes of activity have been identified in plants and animals respectively, the precise wiring and sensitivity of these pathways to CO2 remains to be fully elucidated. In this article, we will give an overview of the literature relating to CO2-dependent signal transduction in mammalian systems. We will highlight the main signal transduction hubs through which CO2-dependent signalling is elicited with a view to better understanding the complex physiological response to CO2 in mammalian systems. The main topics of discussion in this article relate to how changes in CO2 influence cellular function through modulation of signal transduction networks influenced by pH, mitochondrial function, adenylate cyclase, calcium, transcriptional regulators, the adenosine monophosphate-activated protein kinase pathway and direct CO2-dependent protein modifications. While each of these topics will be discussed independently, there is evidence of significant cross-talk between these signal transduction pathways as they respond to changes in CO2. In considering these core hubs of CO2-dependent signal transduction, we hope to delineate common elements and identify areas in which future research could be best directed.
Collapse
Affiliation(s)
- D. E. Phelan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - C. Mota
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - C. Lai
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - S. J. Kierans
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - E. P. Cummins
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| |
Collapse
|
24
|
Korang SK, Safi S, Feinberg J, Nielsen EE, Gluud C, Jakobsen JC. Bicarbonate for acute acidosis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Emil Eik Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Department of Regional Health Research, The Faculty of Health Sciences; University of Southern Denmark; Odense Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Department of Regional Health Research, The Faculty of Health Sciences; University of Southern Denmark; Odense Denmark
| |
Collapse
|
25
|
Nutma S, le Feber J, Hofmeijer J. Neuroprotective Treatment of Postanoxic Encephalopathy: A Review of Clinical Evidence. Front Neurol 2021; 12:614698. [PMID: 33679581 PMCID: PMC7930064 DOI: 10.3389/fneur.2021.614698] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/19/2021] [Indexed: 12/24/2022] Open
Abstract
Postanoxic encephalopathy is the key determinant of death or disability after successful cardiopulmonary resuscitation. Animal studies have provided proof-of-principle evidence of efficacy of divergent classes of neuroprotective treatments to promote brain recovery. However, apart from targeted temperature management (TTM), neuroprotective treatments are not included in current care of patients with postanoxic encephalopathy after cardiac arrest. We aimed to review the clinical evidence of efficacy of neuroprotective strategies to improve recovery of comatose patients after cardiac arrest and to propose future directions. We performed a systematic search of the literature to identify prospective, comparative clinical trials on interventions to improve neurological outcome of comatose patients after cardiac arrest. We included 53 studies on 21 interventions. None showed unequivocal benefit. TTM at 33 or 36°C and adrenaline (epinephrine) are studied most, followed by xenon, erythropoietin, and calcium antagonists. Lack of efficacy is associated with heterogeneity of patient groups and limited specificity of outcome measures. Ongoing and future trials will benefit from systematic collection of measures of baseline encephalopathy and sufficiently powered predefined subgroup analyses. Outcome measurement should include comprehensive neuropsychological follow-up, to show treatment effects that are not detectable by gross measures of functional recovery. To enhance translation from animal models to patients, studies under experimental conditions should adhere to strict methodological and publication guidelines.
Collapse
Affiliation(s)
- Sjoukje Nutma
- Department of Neurology, Medisch Spectrum Twente, Enschede, Netherlands.,Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Joost le Feber
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Jeannette Hofmeijer
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands.,Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
| |
Collapse
|
26
|
Zhou D, Ye Y, Kong Y, Li Z, Shi G, Zhou J. The effect of mild hypercapnia on hospital mortality after cardiac arrest may be modified by chronic obstructive pulmonary disease. Am J Emerg Med 2021; 44:78-84. [PMID: 33582612 DOI: 10.1016/j.ajem.2021.01.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/09/2021] [Accepted: 01/31/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The main objective was to evaluate the effect of carbon dioxide on hospital mortality in chronic obstructive pulmonary disease (COPD) and non-COPD patients with out-of-hospital cardiac arrest (OHCA). METHODS We conducted a retrospective observational study in OHCA patients from the eICU database (eicu-crd.mit.edu). The main exposure was the partial pressure of arterial carbon dioxide (PaCO2). The proportion of time spent (PTS) within four predefined PaCO2 ranges (hypocapnia: <35 mmHg, normocapnia: 35-45 mmHg, mild hypercapnia: 46-55 mmHg, and severe hypercapnia: >55 mmHg) were calculated respectively. The primary outcome was hospital mortality. Multivariable logistic regression models were performed to assess the independent relationship between PTS within PaCO2 range and hospital mortality, and the interaction between PTS within PaCO2 range and COPD was explored. RESULTS A total of 1721 OHCA patients were included, of which 272 (15.8%) had COPD. After adjusted for the confounders, the PTS within mild hypercapnia was associated with lower odds ratio for hospital mortality in COPD patients (OR 0.923; 95% CI 0.857-0.992; P = 0.036); however, it was associated with higher odds ratio for hospital mortality in non-COPD patients (OR 1.053; 95% CI 1.012-1.097; P = 0.012; Pinteraction = 0.008). The PTS within normocapnia was not associated with hospital mortality in COPD patients (OR 0.987; 95% CI 0.914-1.067; P = 0.739); however, it was associated with lower odds ratio for hospital mortality in non-COPD patients (OR 0.944; 95% CI 0.916-0.973; P < 0.001; Pinteraction = 0.113). CONCLUSIONS The effect of carbon dioxide on hospital mortality differed between COPD and non-COPD patients. Mild hypercapnia was associated with increased hospital mortality for non-COPD patients but reduced hospital mortality for COPD patients. It would be reasonable to adjust PaCO2 targets in OHCA patients with COPD.
Collapse
Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ye
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yueyue Kong
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhimin Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
27
|
Kato T, Kasai T, Suda S, Sato A, Ishiwata S, Yatsu S, Matsumoto H, Shitara J, Shimizu M, Murata A, Kagiyama N, Hiki M, Matsue Y, Naito R, Takagi A, Daida H. Prognostic effects of arterial carbon dioxide levels in patients hospitalized into the cardiac intensive care unit for acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:497-502. [PMID: 34192746 DOI: 10.1093/ehjacc/zuab001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/12/2020] [Accepted: 01/06/2021] [Indexed: 11/13/2022]
Abstract
AIMS Although both hypercapnia and hypocapnia are common in acute heart failure (AHF) patients, routine assessment of arterial blood gas is not recommended. Additionally, no association between hypercapnia and increased mortality has been found, and the prognostic value of hypocapnia in AHF patients remains to be elucidated. In this observational study, we aimed to investigate the relationship between partial pressure of arterial carbon dioxide (PaCO2), especially low PaCO2, and long-term mortality in AHF patients. METHODS AND RESULTS Acute heart failure patients hospitalized in the cardiac intensive care unit of our institution between 2007 and 2011 were screened. All eligible patients were divided into two groups based on the inflection point (i.e. 31.0 mmHg) of the 3-knot cubic spline curve of the hazard ratio (HR), with a PaCO2 of 40 mmHg as a reference. The association between PaCO2 levels and all-cause mortality was assessed using Cox proportional hazards regression models. Among 435 patients with a median follow-up of 1.8 years, 115 (26.4%) died. Adjusted analysis with relevant variables as confounders indicated that PaCO2 <31 mmHg was significantly associated with increased all-cause mortality [HR 1.71, 95% confidence interval (CI) 1.05-2.79; P = 0.032]. When PaCO2 was considered as a continuous variable, the lower was the log-transformed PaCO2, the greater was the increased risk of mortality (HR 0.71, 95% CI 0.52-0.96; P = 0.024). CONCLUSIONS In AHF patients, lower PaCO2 at admission was associated with increased long-term mortality risk.
Collapse
Affiliation(s)
- Takao Kato
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital, Tokyo, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Cardiovascular Management and Remote Monitoring, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Digital Health and Telemedicine R&D, Juntendo University Faculty of Health Science, Tokyo, Japan
| | - Shoko Suda
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital, Tokyo, Japan
| | - Akihiro Sato
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Sayaki Ishiwata
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shoichiro Yatsu
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroki Matsumoto
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jun Shitara
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Megumi Shimizu
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Azusa Murata
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Nobuyuki Kagiyama
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Digital Health and Telemedicine R&D, Juntendo University Faculty of Health Science, Tokyo, Japan
| | - Masaru Hiki
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuya Matsue
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ryo Naito
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Atsutoshi Takagi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Digital Health and Telemedicine R&D, Juntendo University Faculty of Health Science, Tokyo, Japan
| |
Collapse
|
28
|
Godoy DA, Rovegno M, Lazaridis C, Badenes R. The effects of arterial CO 2 on the injured brain: Two faces of the same coin. J Crit Care 2020; 61:207-215. [PMID: 33186827 DOI: 10.1016/j.jcrc.2020.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/08/2020] [Accepted: 10/29/2020] [Indexed: 01/14/2023]
Abstract
Serum levels of carbon dioxide (CO2) closely regulate cerebral blood flow (CBF) and actively participate in different aspects of brain physiology such as hemodynamics, oxygenation, and metabolism. Fluctuations in the partial pressure of arterial CO2 (PaCO2) modify the aforementioned variables, and at the same time influence physiologic parameters in organs such as the lungs, heart, kidneys, and the gastrointestinal tract. In general, during acute brain injury (ABI), maintaining normal PaCO2 is the target to be achieved. Both hypercapnia and hypocapnia may comprise secondary insults and should be avoided during ABI. The risks of hypocapnia mostly outweigh the potential benefits. Therefore, its therapeutic applicability is limited to transient and second-stage control of intracranial hypertension. On the other hand, inducing hypercapnia could be beneficial when certain specific situations require increasing CBF. The evidence supporting this claim is very weak. This review attempts providing an update on the physiology of CO2, its risks, benefits, and potential utility in the neurocritical care setting.
Collapse
Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina; Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina.
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Christos Lazaridis
- Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain,; Department of Surgery, University of Valencia, Spain; INCLIVA Research Medical Institute, Valencia, Spain
| |
Collapse
|
29
|
Zhou D, Li Z, Zhang S, Wu L, Li Y, Shi G, Zhou J. Mild hypercapnia improves brain tissue oxygen tension but not diffusion limitation in asphyxial cardiac arrest: an experimental study in pigs. BMC Anesthesiol 2020; 20:252. [PMID: 32993500 PMCID: PMC7522908 DOI: 10.1186/s12871-020-01162-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/15/2020] [Indexed: 01/22/2023] Open
Abstract
Background We sought to evaluate the effect of mild hypercapnia on brain tissue oxygen tension (Pbto2) and diffusion limitation (impaired ability of oxygen extraction) in a porcine post asphyxial cardiac arrest model. Methods In 16 Bama pigs, asphyxial cardiac arrest was induced by endotracheal tube clamping and remained untreated for another 4 min. After return of spontaneous circulation (ROSC), animals were randomly assigned to mild hypercapnia (end-tidal carbon dioxide (EtCO2): 45 ~ 50 mmHg) and normocapnia (EtCO2: 35 ~ 40 mmHg) groups for 12 h. Intracranial pressure (ICP), Pbto2, and brain tissue temperature were invasively measured by multimodality monitors. Blood gas analysis, neuron specific enolase (NSE), and S100β were tested at baseline, ROSC 1 h, 6 h, and 12 h. Generalized mixed model with a compound symmetry covariance matrix was used to compare the time-variables of the two groups. Results Twelve (75%) pigs had ROSC and 11 pigs survived for the study period, with 6 pigs in mild hypercapnia group and 5 in the normocapnia group. The mean EtCO2 in the mild hypercapnia was significantly higher than normocapnia group (48 vs 38 mmHg, p < 0.001). Compared with normocapnia, mild hypercapnia group had higher Pbto2 (p < 0.001), slightly higher mean arterial pressure (p = 0.012) and ICP (p = 0.009). There were no differences in cerebral perfusion pressure (p = 0.106), gradient of partial pressure of jugular venous bulb oxygen (Pjvo2) and Pbto2 (p = 0.262), difference of partial pressure of jugular venous CO2 and arterial CO2 (p = 0.546), cardiac output (p = 0.712), NSE (p = 0.822), and S100β (p = 0.759) between the two groups. Conclusions Short term mild hypercapnia post-resuscitation could improve Pbto2. However, no corresponding improvements in the gradient of Pjvo2 to Pbto2 and biomarkers of neurological recovery were observed in the porcine asphyxial cardiac arrest model.
Collapse
Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Zhimin Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Shaolan Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Lei Wu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Yiyuan Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China.
| |
Collapse
|
30
|
López J, Arias P, Domenech B, Horcajo D, Nocete JP, Zamora L, Fernández SN, López-Herce J. Effect of ventilation rate on recovery after cardiac arrest in a pediatric animal model. PLoS One 2020; 15:e0237736. [PMID: 32817703 PMCID: PMC7440626 DOI: 10.1371/journal.pone.0237736] [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: 04/18/2020] [Accepted: 07/31/2020] [Indexed: 11/19/2022] Open
Abstract
AIMS To assess the impact of two different respiratory rates in hemodynamic, perfusion and ventilation parameters in a pediatric animal model of cardiac arrest (CA). METHODS An experimental randomized controlled trial was carried out in 50 piglets under asphyxial CA. After ROSC, they were randomized into two groups: 20 and 30 respirations per minute (rpm). Hemodynamic, perfusion and ventilation parameters were measured 10 minutes after asphyxia, just before ROSC and at 5, 15, 30 and 60 minutes after ROSC. Independent medians test, Kruskal-Wallis test and χ2 test, were used to compare continuous and categorical variables, respectively. Spearman's Rho was used to assess correlation between continuous variables. A p-value <0.05 was considered significant. RESULTS Arterial partial pressure of carbon dioxide (PaCO2) was significantly lower in the 30 rpm group after 15 minutes (41 vs. 54.5 mmHg, p <0.01), 30 minutes (39.5 vs. 51 mmHg, p < 0.01) and 60 minutes (36.5 vs. 48 mmHg, p = 0.02) of ROSC. The percentage of normoventilated subjects (PaCO2 30-50 mmHg) was significantly higher in the 30 rpm group throughout the experiment. pH normalization occurred faster in the 30 rpm group with significant differences at 60 minutes (7.40 vs. 7.34, p = 0.02). Lactic acid levels were high immediately after ROSC in both groups, but were significantly lower in the 20 rpm group at 30 (3.7 vs. 4.7 p = 0.04) and 60 minutes (2.6 vs. 3.6 p = 0.03). CONCLUSIONS This animal model of asphyxial CA shows that a respiratory rate of 30 rpm is more effective to reach normoventilation than 20 rpm in piglets after ROSC. This ventilation strategy seems to be safe, as it does not cause hyperventilation and does not affect hemodynamics or cerebral tissue perfusion.
Collapse
Affiliation(s)
- Jorge López
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
| | - Patricia Arias
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Beatriz Domenech
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Daniel Horcajo
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| | | | - Laura Zamora
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| |
Collapse
|
31
|
Impact of low and high partial pressure of carbon dioxide on neuron-specific enolase derived from serum and cerebrospinal fluid in patients who underwent targeted temperature management after out-of-hospital cardiac arrest: A retrospective study. Resuscitation 2020; 153:79-87. [PMID: 32531406 DOI: 10.1016/j.resuscitation.2020.05.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/27/2020] [Accepted: 05/31/2020] [Indexed: 02/07/2023]
Abstract
AIM In a previous study, low and high-normal arterial carbon dioxide tension (PaCO2) were not associated with serum neuron-specific enolase (NSE) in cardiac arrest survivors. We assessed the effect of PaCO2 on NSE in cerebrospinal fluid (CSF) and serum. METHODS This was a retrospective study. PaCO2 for the first 24 h was analysed in four means, qualitative exposure state (qES), time-weighted average (TWA), median, and minimum-maximum (Min-Max). These subgroups were divided into low (LCO2) and high PaCO2 (HCO2) groups defined as PaCO2 ≤ 35.3 and PaCO2 > 43.5 mmHg, respectively. NSE was measured at 24, 48, and 72 h (sNSE24,48,72 and cNSE24,48,72) from return of spontaneous circulation (ROSC). The primary outcome was the association between PaCO2 and the NSE measured at 24 h after ROSC. RESULTS Forty-two subjects (male, 33; 78.6%) were included in total cohort. PaCO2 in TWA subgroup was associated with cNSE24,48,72, while PaCO2 in the other subgroup were only associated with cNSE24. PaCO2 and cNSE in qES subgroup showed good correlation (r = -0.61; p < 0.01), and in TWA, median, and Min-Max subgroup showed moderate correlations (r = -0.57, r = -0.48, and r = -0.60; p < 0.01). Contrastively, sNSE was not associated and correlated with PaCO2 in all analysis. Poor neurological outcome in LCO2 was significantly higher than HCO2 in qES, TWA, and median subgroups (p < 0.01, p < 0.01, and p = 0.02). CONCLUSION Association was found between NSE and PaCO2 using CSF, despite including normocapnic ranges; TWA of PaCO2 may be most strongly associated with CSF NSE levels. A prospective, multi-centre study is required to confirm our results.
Collapse
|
32
|
Wong C, Churilov L, Cowie D, Tan CO, Hu R, Tremewen D, Pearce B, Pillai P, Karalapillai D, Bellomo R, Weinberg L. Randomised controlled trial to investigate the relationship between mild hypercapnia and cerebral oxygen saturation in patients undergoing major surgery. BMJ Open 2020; 10:e029159. [PMID: 32066598 PMCID: PMC7045198 DOI: 10.1136/bmjopen-2019-029159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The effects of hypercapnia on regional cerebral oxygen saturation (rSO2) during surgery are unclear. We conducted a randomised controlled trial to investigate the relationship between mild hypercapnia and rSO2. We hypothesised that, compared with targeted normocapnia (TN), targeted mild hypercapnia (TMH) during major surgery would increase rSO2. DESIGN A prospective, randomised, controlled trial in adult participants undergoing elective major surgery. SETTING A single tertiary centre in Heidelberg, Victoria, Australia. PARTICIPANTS 40 participants were randomised to either a TMH or TN group (20 to each). INTERVENTIONS TMH (partial pressure of carbon dioxide in arterial blood, PaCO2, 45-55 mm Hg) or TN (PaCO2 35-40 mm Hg) was delivered via controlled ventilation throughout surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was the absolute difference between the two groups in percentage change in rSO2 from baseline to completion of surgery. Secondary endpoints included intraoperative pH, bicarbonate concentration, base excess, serum potassium concentration, incidence of postoperative delirium and length of stay (LOS) in hospital. RESULTS The absolute difference between the two groups in percentage change in rSO2 from the baseline to the completion of surgery was 19.0% higher in both hemispheres with TMH (p<0.001). On both sides, the percentage change in rSO2 was greater in the TMH group than the TN group throughout the duration of surgery. The difference between the groups became more noticeable over time. Furthermore, postoperative delirium was higher in the TN group (risk difference 0.3, 95% CI 0.1 to 0.5, p=0.02). LOS was similar between groups (5 days vs 5 days; p=0.99). CONCLUSION TMH was associated with a stable increase in rSO2 from the baseline, while TN was associated with a decrease in rSO2 in both hemispheres in patients undergoing major surgery. This resulted in a clear separation of percentage change in rSO2 from the baseline between TMH and TN over time. Our findings provide the rationale for larger studies on TMH during surgery. TRIAL REGISTRATION NUMBER The Australian New Zealand Clinical Trials Registry (ACTRN12616000320459).
Collapse
Affiliation(s)
- Clarence Wong
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- The Department of Medicine, Austin Health, The Univesity of Melbourne, Heidelberg, Victoria, Australia
| | - Dean Cowie
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - David Tremewen
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Param Pillai
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| |
Collapse
|
33
|
Zante B, Hautz WE, Schefold JC. Physiology education for intensive care medicine residents: A 15-minute interactive peer-led flipped classroom session. PLoS One 2020; 15:e0228257. [PMID: 31978206 PMCID: PMC6980559 DOI: 10.1371/journal.pone.0228257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 01/12/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction In acute care medicine, knowledge of the underlying (patho)-physiology is of paramount importance. This may be especially relevant in intensive care medicine, where individual competence and proficiency greatly depend on knowledge and understanding of critical care physiology. In settings with time constraints such as intensive care units (ICUs), time allotted to education is often limited. We evaluated whether introduction of a short, interactive, peer-led flipped classroom session is feasible and can provide ICU residents with a better understanding of critical care physiology. Materials and methods Using the flipped classroom concept, we developed a 15-minute peer-led interactive “physiology education” session to introduce a total of 44 residents to critical care physiology. Using a nine-item electronic survey with open questions and a five-point Likert scale, we analysed the overall concept with regard to feasibility, motivation, and subjective learning of critical care physiology. Results The overall rate of response to the survey was 70.5% (31/44). The residents reported that these sessions sparked their interest (p = 0.005, Chi square 10.52), and that discussion and interaction during these sessions had promoted their knowledge and understanding. Both novice and experienced residents reported that new knowledge was imparted (both p<0.0001, Chi-square 32.97 and 25.04, respectively). Conclusions In an environment with time constraints such as the ICU, a 15-minute, interactive, peer-led flipped classroom teaching session was considered feasible and generally appeared useful for teaching critical care physiology to ICU residents. Responses to questions on questionnaires indicated that teaching sessions sparked interest and increased motivation. This approach may theoretically induce a modification in professional behaviour and promote self-directed learning. We therefore support the use of peer-led flipped classroom training sessions in the ICU. Whether these sessions result in improved ICU care should be addressed in subsequent studies.
Collapse
Affiliation(s)
- Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Wolf E. Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C. Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
34
|
Tiwari S, Garg PK, Patavardhan P, Chauhan NK, Bhaskar S, Khera PS. Pseudo-subarachnoid Hemorrhage in a Patient with Acute on Chronic Respiratory Failure. Ann Indian Acad Neurol 2020; 23:706-708. [PMID: 33623278 PMCID: PMC7887467 DOI: 10.4103/aian.aian_257_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India,Address for correspondence: Dr. Pawan Kumar Garg, Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India. E-mail:
| | - Preetham Patavardhan
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nishant Kumar Chauhan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Suryanarayanan Bhaskar
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pushpinder Singh Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|
35
|
Szakmar E, Kovacs K, Meder U, Bokodi G, Andorka C, Lakatos A, Szabo AJ, Belteki G, Szabo M, Jermendy A. Neonatal encephalopathy therapy optimization for better neuroprotection with inhalation of CO 2: the HENRIC feasibility and safety trial. Pediatr Res 2020; 87:1025-1032. [PMID: 31785594 PMCID: PMC7223064 DOI: 10.1038/s41390-019-0697-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/26/2019] [Accepted: 10/09/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND There is an association between hypocapnia and adverse neurodevelopmental outcome in infants with neonatal encephalopathy (NE). Our aim was to test the safety and feasibility of 5% CO2 and 95% air inhalation to correct hypocapnia in mechanically ventilated infants with NE undergoing therapeutic hypothermia. METHODS Ten infants were assigned to this open-label, single-center trial. The gas mixture of 5% CO2 and 95% air was administered through patient circuits if the temperature-corrected PCO2 ≤40 mm Hg. The CO2 inhalation was continued for 12 h or was stopped earlier if the base deficit (BD) level decreased <5 mmol/L. Follow-up was performed using Bayley Scales of Infant Development II. RESULTS The patients spent a median 95.1% (range 44.6-98.5%) of time in the desired PCO2 range (40-60 mm Hg) during the inhalation. All PCO2 values were >40 mm Hg, the lower value of the target range. Regression modeling revealed that BD and lactate had a tendency to decrease during the intervention (by 0.61 and 0.55 mmol/L/h, respectively), whereas pH remained stable. The rate of moderate disabilities and normal outcome was 50%. CONCLUSIONS Our results suggest that inhaled 5% CO2 administration is a feasible and safe intervention for correcting hypocapnia.
Collapse
Affiliation(s)
- Eniko Szakmar
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Kata Kovacs
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Unoke Meder
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Geza Bokodi
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Csilla Andorka
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Andrea Lakatos
- grid.11804.3c0000 0001 0942 9821MR Research Centre, Semmelweis University, Budapest, Hungary
| | - Attila J. Szabo
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary ,grid.5018.c0000 0001 2149 4407MTA-SE Paediatric and Nephrology Research Group, Budapest, Hungary
| | - Gusztav Belteki
- grid.24029.3d0000 0004 0383 8386Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Miklos Szabo
- grid.11804.3c0000 0001 0942 98211st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Agnes Jermendy
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary.
| |
Collapse
|
36
|
Karagiannidis C, Merten ML, Heunks L, Strassmann SE, Schäfer S, Magnet F, Windisch W. Respiratory acidosis during bronchoscopy-guided percutaneous dilatational tracheostomy: impact of ventilator settings and endotracheal tube size. BMC Anesthesiol 2019; 19:147. [PMID: 31399057 PMCID: PMC6689167 DOI: 10.1186/s12871-019-0824-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
Background The current study investigates the effect of bronchoscopy-guided percutaneous dilatational tracheostomy (PDT) on the evolution of respiratory acidosis depending on endotracheal tube (ET) sizes. In addition, the impact of increasing tidal volumes during the intervention was investigated. Methods Two groups of ICU-patients undergoing bronchoscopy-guided PDT with varying tidal volumes and tube sizes were consecutively investigated: 6 ml/kg (N = 29, mean age 57.4 ± 14.5 years) and 12 ml/kg predicted body weight (N = 34, mean age 59.5 ± 12.8 years). Results The mean intervention time during all procedures was 10 ± 3 min. The combination of low tidal volumes and ETs of 7.5 mm internal diameter resulted in the most profound increase in PaCO2 (32.2 ± 11.6 mmHg) and decrease in pH-value (− 0.18 ± 0.05). In contrast, the combination of high tidal volumes and ETs of 8.5 mm internal diameter resulted in the least profound increase in PaCO2 (8.8 ± 9.0 mmHg) and decrease of pH (− 0.05 ± 0.04). The intervention-related increase in PaCO2 was significantly lower when using higher tidal volumes for larger ET: internal diameter 7.5, 8.0 and 8.5: P > 0.05, =0.006 and = 0.002, respectively. Transcutaneous PCO2 monitoring revealed steadily worsening hypercapnia during the intervention with a high correlation of 0.87 and a low bias of 0.7 ± 9.4 mmHg according to the Bland-Altman analysis when compared to PaCO2 measurements. Conclusions Profound respiratory acidosis following bronchoscopy-guided PDT evolves in a rapid and dynamic process. Increasing the tidal volume from 6 to 12 ml/kg PBW was capable of attenuating the evolution of respiratory acidosis, but this effect was only evident when using larger ETs. Trial registration DRKS00011004. Registered 20th September 2016. Electronic supplementary material The online version of this article (10.1186/s12871-019-0824-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Michaela L Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Leo Heunks
- Dept of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Stephan E Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Simone Schäfer
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Friederike Magnet
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| |
Collapse
|
37
|
Extracorporeal carbon dioxide removal for lowering the risk of mechanical ventilation: research questions and clinical potential for the future. THE LANCET RESPIRATORY MEDICINE 2019; 6:874-884. [PMID: 30484429 DOI: 10.1016/s2213-2600(18)30326-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/28/2018] [Accepted: 07/19/2018] [Indexed: 12/30/2022]
Abstract
As a result of technical improvements, extracorporeal carbon dioxide removal (ECCO2R) now has the potential to play an important role in the management of adults with acute respiratory failure. There is growing interest in the use of ECCO2R for the management of both hypoxaemic and hypercapnic respiratory failure. However, evidence to support its use is scarce and several questions remain about the best way to implement this therapy, which can be associated with serious side-effects. This Review reflects the consensus opinion of an international group of clinician scientists with expertise in managing acute respiratory failure and in using ECCO2R therapies in this setting. We concisely review clinically relevant aspects of ECCO2R, and provide a series of recommendations for clinical practice and future research, covering topics that include the practicalities of ECCO2R delivery, indications for use, and service delivery.
Collapse
|
38
|
Do acute stroke patients develop hypocapnia? A systematic review and meta-analysis. J Neurol Sci 2019; 402:30-39. [DOI: 10.1016/j.jns.2019.04.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/12/2019] [Accepted: 04/29/2019] [Indexed: 12/14/2022]
|
39
|
Szakmar E, Jermendy A, El-Dib M. Respiratory management during therapeutic hypothermia for hypoxic-ischemic encephalopathy. J Perinatol 2019; 39:763-773. [PMID: 30858610 DOI: 10.1038/s41372-019-0349-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/18/2019] [Accepted: 01/30/2019] [Indexed: 01/01/2023]
Abstract
Therapeutic hypothermia (TH) has become the standard of care treatment to improve morbidity and mortality in infants with hypoxic-ischemic encephalopathy (HIE). Although TH has clearly proven to be beneficial, recent studies suggest optimization of respiratory management as an approach to prevent further damage and improve neurodevelopmental outcome. The ventilatory management of asphyxiated neonates presents a challenge because both the hypoxic insult and TH have an impact on respiratory functions. Although the danger of recurrence of hypocapnia is well recognized, a brief period of severe hyperoxia also can be detrimental to the previously compromised brain and have been shown to increase the risk of adverse neurodevelopmental outcomes. Therefore, judicious ventilatory management with rigorous monitoring is of particular importance in patients with HIE. In the present review, we provide an overview of the currently available evidence on pulmonary function, respiratory morbidities, and ventilation strategies in HIE and we highlight possible future research directions.
Collapse
Affiliation(s)
- Eniko Szakmar
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary.,Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Agnes Jermendy
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|
40
|
Changes in the SID Actual and SID Effective Values in the Course of Respiratory Acidosis in Horses With Symptomatic Severe Equine Asthma-An Experimental Study. J Equine Vet Sci 2019; 78:107-111. [PMID: 31203972 DOI: 10.1016/j.jevs.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 04/20/2019] [Accepted: 05/01/2019] [Indexed: 11/20/2022]
Abstract
Equine asthma syndrome is an allergic, inflammatory airway disease that usually affects older horses. Respiratory acidosis is an acid-base imbalance caused by alveolar hypoventilation. The acid-base balance may be assessed using the Henderson-Hasselbalch equation as well as the Stewart model. The authors hypothesized that systemic respiratory acidosis changes the ionic concentrations affecting water dissociation. The study group included 16 Warmblood, mixed breed horses of both sexes with a history of severe equine asthma, and 10 healthy horses were used as controls. Arterial and venous blood were collected from all the horses. The pH, pO2, and pCO2 and HCO3- were assessed in the arterial blood. Na, K, Cl, albumin, and Pinorganic (Pi) were assessed in the venous blood. The obtained results were used to calculate the anion gap (AG), modified AG, actual strong ion difference (SIDa), weak non-volatile acids, and effective strong ion difference (SIDe) values for all the horses. A systemic, compensatory respiratory acidosis was diagnosed in the study group. The concentration of Na in the blood serum in the study group was significantly higher, whereas the concentration of Cl was significantly lower than the values in the control group. The SIDa and SIDe values calculated in the horses from the study group were significantly higher than those in the control group. Significantly higher SIDa and SIDe values confirm the presence of ionic changes that affect water dissociation in the course of respiratory acidosis in horses. The SIDa and SIDe values may be useful in the diagnosis and treatment of respiratory acidosis in horses, which warrant further investigation.
Collapse
|
41
|
Chan MJ, Lucchetta L, Cutuli S, Eyeington C, Glassford NJ, Mårtensson J, Angelopoulos P, Matalanis G, Weinberg L, Eastwood GM, Bellomo R. A Pilot Randomized Controlled Study of Mild Hypercapnia During Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2019; 33:2968-2978. [PMID: 31072710 DOI: 10.1053/j.jvca.2019.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To test whether targeted therapeutic mild hypercapnia (TTMH) would attenuate cerebral oxygen desaturation detected using near-infrared spectroscopy during cardiac surgery requiring cardiopulmonary bypass (CPB). DESIGN Randomized controlled trials. SETTING Operating rooms and intensive care unit of tertiary hospital. PARTICIPANTS The study comprised 30 patients undergoing cardiac surgery with CPB. INTERVENTIONS Patients were randomly assigned to receive either standard carbon dioxide management (normocapnia) or TTMH (target arterial carbon dioxide partial pressure between 50 and 55 mmHg) throughout the intraoperative period and postoperatively until the onset of spontaneous ventilation. MEASUREMENTS AND MAIN RESULTS Relevant biochemical and hemodynamic variables were measured, and cerebral tissue oxygen saturation (SctO2) was monitored with near-infrared spectroscopy. Patients were followed-up with neuropsychological testing. Patient demographics between groups were compared using the Fisher exact and Mann-Whitney tests, and SctO2 between groups was compared using repeated measures analysis of variance. The median patient age was 67 years (interquartile range [IQR] 62-72 y), and the median EuroSCORE II was 1.1. The median CPB time was 106 minutes. The mean intraoperative arterial carbon dioxide partial pressure for each patient was significantly higher with TTMH (52.1 mmHg [IQR 49.9-53.9 mmHg] v 40.8 mmHg [IQR 38.7-41.7 mmHg]; p < 0.001) as was pulmonary artery pressure (23.9 mmHg [IQR 22.4-25.3 mmHg] v 18.5 mmHg [IQR 14.8-20.7 mmHg]; p = 0.004). There was no difference in mean percentage change in SctO2 during CPB in the control group for both hemispheres (left: -6.7% v -2.3%; p = 0.110; right: -7.9% v -1.0%; p = 0.120). Compliance with neuropsychological test protocols was poor. However, the proportion of patients with drops in test score >20% was similar between groups in all tests. CONCLUSIONS TTMH did not increase SctO2 appreciably during CPB but increased pulmonary artery pressures before and after CPB. These findings do not support further investigation of TTMH as a means of improving SctO2 during and after cardiac surgery requiring CPB.
Collapse
Affiliation(s)
- Matthew J Chan
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Luca Lucchetta
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Salvatore Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia
| | | | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; School of Medicine, University of Melbourne, Melbourne, Australia; Data Assessment Research Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, Australia.
| |
Collapse
|
42
|
Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med 2019; 45:592-600. [DOI: 10.1007/s00134-019-05567-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
|
43
|
Lyons C, Callaghan M. Uses and mechanisms of apnoeic oxygenation: a narrative review. Anaesthesia 2019; 74:497-507. [DOI: 10.1111/anae.14565] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2018] [Indexed: 12/31/2022]
Affiliation(s)
- C. Lyons
- Department of Anaesthesia; Mater Misericordiae University Hospital; Dublin Ireland
| | - M. Callaghan
- Department of Anaesthesia; Galway University Hospitals; Galway Ireland
| |
Collapse
|
44
|
Babini G, Ristagno G, Boccardo A, De Giorgio D, De Maglie M, Affatato R, Ceriani S, Zani D, Novelli D, Staszewsky L, Masson S, Pravettoni D, Latini R, Belloli A, Scanziani E, Skrifvars M. Effect of mild hypercapnia on outcome and histological injury in a porcine post cardiac arrest model. Resuscitation 2019; 135:110-117. [DOI: 10.1016/j.resuscitation.2018.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 10/02/2018] [Accepted: 10/25/2018] [Indexed: 10/28/2022]
|
45
|
Al-Dorzi HM, Aldawood AS, Tamim H, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakhija M, Sadat M, Afesh L, Kumar A, Bagshaw SM, Mehta S, M Arabi Y. Caloric intake and the fat-to-carbohydrate ratio in hypercapnic acute respiratory failure: Post-hoc analysis of the PermiT trial. Clin Nutr ESPEN 2018; 29:175-182. [PMID: 30661684 DOI: 10.1016/j.clnesp.2018.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of moderate caloric enteral intake in critically ill patients with hypercapnic acute respiratory failure (HCARF) is unclear. We studied the impact of permissive underfeeding (PUF) compared with standard feeding (SF) on various HCARF outcomes. MATERIALS AND METHODS The PermiT trial randomized 894 patients to either PUF (40-60% caloric requirement) or SF (70-100% requirement) with similar protein intake and found no difference in mortality, mechanical ventilation (MV) duration and ventilator-free days. In this post-hoc study, we restricted analysis to mechanically-ventilated patients with HCARF (PaCO2 >45 mmHg on the first two study days) and assessed the impact of trial interventions and fat-to-carbohydrate ratio on outcomes. RESULTS One-hundred-twenty patients had HCARF (59 PUF and 61 SF, age 53.7 ± 17.8 years, body mass index 31.1 ± 11.2 kg/m2, Acute Physiology and Chronic Health Evaluation II score 21.7 ± 7.1 and day-1 PaCO2 61 ± 16 mmHg). Caloric intake was 815 ± 270 kcal/day in PUF group and 1289 ± 407 kcal/day in SF group. The two groups had similar PaCO2 levels during ICU stay. The 90-day mortality (33.9% versus 35.6%, p = 0.85), MV duration (10.7 ± 6.8 versus 11.1 ± 8.1 days, p = 0.56) and ventilator-free days (52.9 ± 38.6 versus 51.2 ± 38.0 days, p = 0.80) were also similar in PUF and SF groups, respectively. Ventilator-free days and 90-day mortality were similar when the fat-to-carbohydrate ratio was < or ≥ the median value (0.73) in all patients and in PUF and SF groups. CONCLUSIONS In patients with HCARF, SF and PUF were associated with similar PaCO2, MV duration, ventilator-free days and mortality. Fat-to-carbohydrate ratio was not associated with mortality or ventilator-free days. TRIAL REGISTRATION ISRCTN Registry: ISRCTN68144998.
Collapse
Affiliation(s)
- Hasan M Al-Dorzi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Abdulaziz S Aldawood
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Hani Tamim
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon.
| | - Samir H Haddad
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Gwynne Jones
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lauralyn McIntyre
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Othman Solaiman
- Department of Adult Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh 11426, Saudi Arabia.
| | - Maram Sakhija
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Musharaf Sadat
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Lara Afesh
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| |
Collapse
|
46
|
Rentola R, Hästbacka J, Heinonen E, Rosenberg PH, Häggblom T, Skrifvars MB. Estimation of Arterial Carbon Dioxide Based on End-Tidal Gas Pressure and Oxygen Saturation. J Clin Med 2018; 7:jcm7090290. [PMID: 30235787 PMCID: PMC6162395 DOI: 10.3390/jcm7090290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 11/16/2022] Open
Abstract
Arterial blood gas (ABG) analysis is the traditional method for measuring the partial pressure of carbon dioxide. In mechanically ventilated patients a continuous noninvasive monitoring of carbon dioxide would obviously be attractive. In the current study, we present a novel formula for noninvasive estimation of arterial carbon dioxide. Eighty-one datasets were collected from 19 anesthetized and mechanically ventilated pigs. Eleven animals were mechanically ventilated without interventions. In the remaining eight pigs the partial pressure of carbon dioxide was manipulated. The new formula (Formula 1) is PaCO2 = PETCO2 + k(PETO2 − PaO2) where PaO2 was calculated from the oxygen saturation. We tested the agreements of this novel formula and compared it to a traditional method using the baseline PaCO2 − ETCO2 gap added to subsequently measured, end-tidal carbon dioxide levels (Formula 2). The mean difference between PaCO2 and calculated carbon dioxide (Formula 1) was 0.16 kPa (±SE 1.17). The mean difference between PaCO2 and carbon dioxide with Formula 2 was 0.66 kPa (±SE 0.18). With a mixed linear model excluding cases with cardiorespiratory collapse, there was a significant difference between formulae (p < 0.001), as well as significant interaction between formulae and time (p < 0.001). In this preliminary animal study, this novel formula appears to have a reasonable agreement with PaCO2 values measured with ABG analysis, but needs further validation in human patients.
Collapse
Affiliation(s)
- Raisa Rentola
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland.
| | - Johanna Hästbacka
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland.
| | - Erkki Heinonen
- Clinical Care Solutions, Anaesthesia and Respiratory Care, 00510 Helsinki, Finland.
| | - Per H Rosenberg
- Division of Anaesthesia, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland.
| | - Tom Häggblom
- Clinical Care Solutions, Anaesthesia and Respiratory Care, 00510 Helsinki, Finland.
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland.
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, 00290 Helsinki, Finland.
| |
Collapse
|
47
|
Thome UH, Dreyhaupt J, Genzel-Boroviczeny O, Bohnhorst B, Schmid M, Fuchs H, Rohde O, Avenarius S, Topf HG, Zimmermann A, Faas D, Timme K, Kleinlein B, Buxmann H, Schenk W, Segerer H, Teig N, Ackermann B, Hentschel R, Heckmann M, Schlösser R, Peters J, Rossi R, Rascher W, Böttger R, Seidenberg J, Hansen G, Bode H, Zernickel M, Muche R, Hummler HD. Influence of PCO2 Control on Clinical and Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants. Neonatology 2018; 113:221-230. [PMID: 29298438 DOI: 10.1159/000485828] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levels or fluctuations in the partial pressure of CO2 (PCO2) may affect outcomes for extremely low birth weight infants. OBJECTIVES In an exploratory analysis of a randomized trial, we hypothesized that the PCO2 values achieved could be related to significant outcomes. METHODS On each treatment day, infants were divided into 4 groups: relative hypocapnia, normocapnia, hypercapnia, or fluctuating PCO2. Ultimate assignment to a group for the purpose of this analysis was made according to the group in which an infant spent the most days. Statistical analyses were performed with analysis of variance (ANOVA), the Kruskal-Wallis test, the χ2 test, and the Fisher exact test as well as by multiple logistic regression. RESULTS Of the 359 infants, 57 were classified as hypocapnic, 230 as normocapnic, 70 as hypercapnic, and 2 as fluctuating PCO2. Hypercapnic infants had a higher average product of mean airway pressure and fraction of inspired oxygen (MAP × FiO2). For this group, mortality was higher, as was the likelihood of having moderate/severe bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and poorer neurodevelopment. Multiple logistic regression analyses showed an increased risk for BPD or death associated with birth weight (p < 0.001) and MAP × FiO2 (p < 0.01). The incidence of adverse neurodevelopment was associated with birth weight (p < 0.001) and intraventricular hemorrhage (IVH; p < 0.01). CONCLUSIONS Birth weight and respiratory morbidity, as measured by MAP × FiO2, were the most predictive of death or BPD and NEC, whereas poor neurodevelopmental outcome was associated with low birth weight and IVH. Univariate models also identified PCO2. Thus, hypercapnia seems to reflect greater disease severity, a likely contributor to differences in outcomes.
Collapse
Affiliation(s)
- Ulrich H Thome
- Division of Neonatology, University Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Lyons C, Callaghan M. Apnoeic oxygenation with high-flow nasal oxygen for laryngeal surgery: a case series. Anaesthesia 2017; 72:1379-1387. [DOI: 10.1111/anae.14036] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2017] [Indexed: 12/16/2022]
Affiliation(s)
- C. Lyons
- Department of Anaesthesia; Galway University Hospitals; Galway Ireland
| | - M. Callaghan
- Department of Anaesthesia; Galway University Hospitals; Galway Ireland
| |
Collapse
|
49
|
Fuller BM, Mohr NM, Drewry AM, Ferguson IT, Trzeciak S, Kollef MH, Roberts BW. Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study. J Crit Care 2017; 41:29-35. [PMID: 28472700 PMCID: PMC5633513 DOI: 10.1016/j.jcrc.2017.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/18/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe the prevalence of hypocapnia and hypercapnia during the earliest period of mechanical ventilation, and determine the association between PaCO2 and mortality. MATERIALS AND METHODS A cohort study using an emergency department registry of mechanically ventilated patients. PaCO2 was categorized: hypocapnia (<35mmHg), normocapnia (35-45mmHg), and hypercapnia (>45mmHg). The primary outcome was survival to hospital discharge. RESULTS A total of 1,491 patients were included. Hypocapnia occurred in 375 (25%) patients and hypercapnia in 569 (38%). Hypercapnia (85%) had higher survival rate compared to normocapnia (74%) and hypocapnia (66%), P<0.001. PaCO2 was an independent predictor of survival to hospital discharge [hypocapnia (aOR 0.65 (95% confidence interval [CI] 0.48-0.89), normocapnia (reference category), hypercapnia (aOR 1.83 (95% CI 1.32-2.54)]. Over ascending ranges of PaCO2, there was a linear trend of increasing survival up to a PaCO2 range of 66-75mmHg, which had the strongest survival association, aOR 3.18 (95% CI 1.35-7.50). CONCLUSIONS Hypocapnia and hypercapnia occurred frequently after initiation of mechanical ventilation. Higher PaCO2 levels were associated with increased survival. These data provide rationale for a trial examining the optimal PaCO2 in the critically ill.
Collapse
Affiliation(s)
- Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, United States.
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242, United States.
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, United States.
| | - Ian T Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin 4, Ireland.
| | - Stephen Trzeciak
- Departments of Medicine and Emergency Medicine, Division of Critical Care Medicine, Cooper University Hospital, One Cooper Plaza, K152, Camden, NJ 08103, United States.
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, United States.
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, One Cooper Plaza, K152, Camden, NJ 08103, United States.
| |
Collapse
|
50
|
Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of Hypercapnia and Hypercapnic Acidosis on Hospital Mortality in Mechanically Ventilated Patients. Crit Care Med 2017; 45:e649-e656. [PMID: 28406813 DOI: 10.1097/ccm.0000000000002332] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Lung-protective ventilation is used to prevent further lung injury in patients on invasive mechanical ventilation. However, lung-protective ventilation can cause hypercapnia and hypercapnic acidosis. There are no large clinical studies evaluating the effects of hypercapnia and hypercapnic acidosis in patients requiring mechanical ventilation. DESIGN Multicenter, binational, retrospective study aimed to assess the impact of compensated hypercapnia and hypercapnic acidosis in patients receiving mechanical ventilation. SETTINGS Data were extracted from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database over a 14-year period where 171 ICUs contributed deidentified data. PATIENTS Patients were classified into three groups based on a combination of pH and carbon dioxide levels (normocapnia and normal pH, compensated hypercapnia [normal pH with elevated carbon dioxide], and hypercapnic acidosis) during the first 24 hours of ICU stay. Logistic regression analysis was used to identify the independent association of hypercapnia and hypercapnic acidosis with hospital mortality. INTERVENTIONS Nil. MEASUREMENTS AND MAIN RESULTS A total of 252,812 patients (normocapnia and normal pH, 110,104; compensated hypercapnia, 20,463; and hypercapnic acidosis, 122,245) were included in analysis. Patients with compensated hypercapnia and hypercapnic acidosis had higher Acute Physiology and Chronic Health Evaluation III scores (49.2 vs 53.2 vs 68.6; p < 0.01). The mortality was higher in hypercapnic acidosis patients when compared with other groups, with the lowest mortality in patients with normocapnia and normal pH. After adjusting for severity of illness, the adjusted odds ratio for hospital mortality was higher in hypercapnic acidosis patients (odds ratio, 1.74; 95% CI, 1.62-1.88) and compensated hypercapnia (odds ratio, 1.18; 95% CI, 1.10-1.26) when compared with patients with normocapnia and normal pH (p < 0.001). In patients with hypercapnic acidosis, the mortality increased with increasing PCO2 until 65 mm Hg after which the mortality plateaued. CONCLUSIONS Hypercapnic acidosis during the first 24 hours of intensive care admission is more strongly associated with increased hospital mortality than compensated hypercapnia or normocapnia.
Collapse
Affiliation(s)
- Ravindranath Tiruvoipati
- 1Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia.2Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.3ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, VIC, Australia.4Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia.5University of New South Wales, Kensington, NSW, Australia
| | | | | | | | | |
Collapse
|