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Canadian Journal of Anesthesia/Journal canadien d'anesthésie

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01-01-2022 | Heart Surgery | Reports of Original Investigations

Difference between arterial and end-tidal carbon dioxide and adverse events after non-cardiac surgery: a historical cohort study

Authors: Ryan Davis, MD, Elizabeth Jewell, MS, Milo Engoren, MD, Michael Maile, MD

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 1/2022

Abstract

Purpose

The difference between arterial and end-tidal partial pressure of carbon dioxide (ΔCO₂) is a measure of alveolar dead space, commonly evaluated intraoperatively. Given its relationship to ventilation and perfusion, ΔCO₂ may provide prognostic information and guide clinical decisions. We hypothesized that higher ΔCO₂ values are associated with occurrence of a composite outcome of re-intubation, postoperative mechanical ventilation, or 30-day mortality in patients undergoing non-cardiac surgery.

Methods

We conducted a historical cohort study of adult patients undergoing non-cardiac surgery with an arterial line at a single tertiary care medical centre. The composite outcome, identified from electronic health records, was re-intubation, postoperative mechanical ventilation, or 30-day mortality. Student’s t test and Chi-squared test were used for univariable analysis. Logistic regression was used for multivariable analysis of the relationship of ΔCO₂ with the composite outcome.

Results

A total of 19,425 patients were included in the final study population. Univariable analysis showed an association between higher mean (standard deviation [SD]) intraoperative ΔCO₂ values and the composite outcome (6.1 [5.3] vs 5.7 [4.5] mm Hg; P = 0.002). After adjusting for baseline subject characteristics, every 5-mm Hg increase in the ΔCO₂ was associated with a nearly 20% increased odds of the composite outcome (odds ratio, 1.20; 95% confidence interval, 1.12 to 1.28; P < 0.001).

Conclusions

In this patient population, increased intraoperative ΔCO₂ was associated with an increased odds of the composite outcome of postoperative mechanical ventilation, re-intubation, or 30-day mortality that was independent of its relationship with pre-existing pulmonary disease. Future studies are needed to determine if ΔCO₂ can be used to guide patient management and improve patient outcomes.

Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242: 326-41.PubMedCrossRefPubMedCentral

Smetana GW. Postoperative pulmonary complications: an update on risk assessment and reduction. Cleve Clin J Med 2009; 76 Suppl 4: S60-5.PubMedCrossRef

Nafiu OO, Ramachandran SK, Ackwerh R, Tremper KK, Campbell DA Jr, Stanley JC. Factors associated with and consequences of unplanned post-operative intubation in elderly vascular and general surgery patients. Eur J Anaesthesiol 2011; 28: 220-4.PubMedCrossRef

Ramachandran SK, Nafiu OO, Ghaferi A, Tremper KK, Shanks A, Kheterpal S. Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery. Anesthesiology 2011; 115: 44-53.PubMedCrossRef

Ladha K, Vidal Melo MF, McLean DJ, et al. Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study. BMJ 2015; DOI: https://doi.org/10.1136/bmj.h3646.PubMedCrossRefPubMedCentral

Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369: 428-37.PubMedCrossRef

Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology 2013; 118: 1307-21.PubMedCrossRef

Fernandez-Perez ER, Sprung J, Afessa B, et al. Intraoperative ventilator settings and acute lung injury after elective surgery: a nested case control study. Thorax 2009; 64: 121-7.PubMedCrossRef

Nassar BS, Schmidt GA. Estimating arterial partial pressure of carbon dioxide in ventilated patients: how valid are surrogate measures? Ann Am Thorac Soc 2017; 14: 1005-14.PubMedCrossRef

10.

Nunn JF. Nunn's Applied Respiratory Physiology, 2nd ed. London: Butterworths; 1977: 220-2.

11.

Luostarinen T, Dilmen OK, Niiya T, Niemi T. Effect of arterial blood pressure on the arterial to end-tidal carbon dioxide difference during anesthesia induction in patients scheduled for craniotomy. J Neurosurg Anesthesiol 2010; 22: 303-8.PubMedCrossRef

12.

Casati A, Salvo I, Torri G, Calderini E. Arterial to end-tidal carbon dioxide gradient and physiological dead space monitoring during general anaesthesia: effects of patients' position. Minerva Anestesiol 1997; 63: 177-82.PubMed

13.

Domsky M, Wilson RF, Heins J. Intraoperative end-tidal carbon dioxide values and derived calculations correlated with outcome: prognosis and capnography. Crit Care Med 1995; 23: 1497-503.PubMedCrossRef

14.

Nuckton TJ, Alonso JA, Kallet RH, et al. Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 2002; 346: 1281-6.PubMedCrossRef

15.

Cepkova M, Kapur V, Ren X, et al. Pulmonary dead space fraction and pulmonary artery systolic pressure as early predictors of clinical outcome in acute lung injury. Chest 2007; 132: 836-42.PubMedCrossRef

16.

Raurich JM, Vilar M, Colomar A, et al. Prognostic value of the pulmonary dead-space fraction during the early and intermediate phases of acute respiratory distress syndrome. Respir Care 2010; 55: 282-7.PubMed

17.

Maisch S, Reissmann H, Fuellekrug B, et al. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients. Anesth Analg 2008; 106: 175-81.PubMedCrossRef

18.

Tusman G, Suarez-Sipmann F, Bohm SH, et al. Monitoring dead space during recruitment and PEEP titration in an experimental model. Intensive Care Med 2006; 32: 1863-71.PubMedCrossRef

19.

Fengmei G, Jin C, Songqiao L, Congshan Y, Yi Y. Dead space fraction changes during PEEP titration following lung recruitment in patients with ARDS. Respir Care 2012; 57: 1578-85.PubMedCrossRef

20.

Nunn JF, Hill DW. Respiratory dead space and arterial to end-tidal carbon dioxide tension difference in anesthetized man. J Appl Physiol 1960; 15: 383-9.PubMedCrossRef

21.

Hardman JG, Aitkenhead AR. Estimating alveolar dead space from the arterial to end-tidal CO(2) gradient: a modeling analysis. Anesth Analg 2003; 97: 1846-51.PubMedCrossRef

22.

Grenier B, Verchere E, Mesli A, et al. Capnography monitoring during neurosurgery: reliability in relation to various intraoperative positions. Anesth Analg 1999; 88: 43-8.PubMed

23.

McDonald MJ, Montgomery VL, Cerrito PB, Parrish CJ, Boland KA, Sullivan JE. Comparison of end-tidal CO2 and Paco2 in children receiving mechanical ventilation. Pediatr Crit Care Med 2002; 3: 244-9.PubMedCrossRef

24.

Short JA, Paris ST, Booker PD, Fletcher R. Arterial to end-tidal carbon dioxide tension difference in children with congenital heart disease. Br J Anaesth 2001; 86: 349-53.PubMedCrossRef

25.

Russell GB, Graybeal JM. Reliability of the arterial to end-tidal carbon dioxide gradient in mechanically ventilated patients with multisystem trauma. J Trauma 1994; 36: 317-22.PubMedCrossRef

26.

Kerr ME, Zempsky J, Sereika S, Orndoff P, Rudy EB. Relationship between arterial carbon dioxide and end-tidal carbon dioxide in mechanically ventilated adults with severe head trauma. Crit Care Med 1996; 24: 785-90.PubMedCrossRef

27.

Tobias JD, Meyer DJ. Noninvasive monitoring of carbon dioxide during respiratory failure in toddlers and infants: end-tidal versus transcutaneous carbon dioxide. Anesth Analg 1997; 85: 55-8.PubMed

28.

Berkenbosch JW, Lam J, Burd RS, Tobias JD. Noninvasive monitoring of carbon dioxide during mechanical ventilation in older children: end-tidal versus transcutaneous techniques. Anesth Analg 2001; 92: 1427-31.PubMedCrossRef

29.

Tyburski JG, Carlin AM, Harvey EH, Steffes C, Wilson RF. End-tidal CO2-arterial CO2 differences: a useful intraoperative mortality marker in trauma surgery. J Trauma 2003; 55: 892-6.PubMedCrossRef

30.

Plantier L, Cazes A, Dinh-Xuan AT, Bancal C, Marchand-Adam S, Crestani B. Physiology of the lung in idiopathic pulmonary fibrosis. Eur Respir Rev 2018; DOI: https://doi.org/10.1183/16000617.0062-2017.PubMedCrossRef

31.

McSwain SD, Hamel DS, Smith PB, et al. End-tidal and arterial carbon dioxide measurements correlate across all levels of physiologic dead space. Respir Care 2010; 55: 288-93.PubMed

32.

Yousuf T, Brinton T, Murtaza G, et al. Establishing a gradient between partial pressure of arterial carbon dioxide and end-tidal carbon dioxide in patients with acute respiratory distress syndrome. J Investig Med 2017; 65: 338-41.PubMedCrossRef

33.

Morales-Quinteros L, Schultz MJ, Bringue J, et al. Estimated dead space fraction and the ventilatory ratio are associated with mortality in early ARDS. Ann Intensive Care 2019; DOI: https://doi.org/10.1186/s13613-019-0601-0.PubMedCrossRefPubMedCentral

34.

Moon SW, Lee SW, Choi SH, Hong YS, Kim SJ, Kim NH. Arterial minus end-tidal CO2 as a prognostic factor of hospital survival in patients resuscitated from cardiac arrest. Resuscitation 2007; 72: 219-25.PubMedCrossRef

35.

Mahajan S, Chauhan R, Luthra A, Bala I, Bharti N, Sharma A. Evaluation of arterial to end-tidal carbon dioxide pressure differences during laparoscopic renal surgery in the lateral decubitus position. Anesth Essays Res 2019; 13: 583-8.PubMedCrossRefPubMedCentral

36.

Shankar KB, Moseley H, Kumar Y, Vemula V, Krishnan A. Arterial to end-tidal carbon dioxide tension difference during anaesthesia for tubal ligation. Anaesthesia 1987; 42: 482-6.PubMedCrossRef

37.

Canet J, Sabate S, Mazo V, et al. Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: a prospective, observational study. Eur J Anaesthesiol 2015; 32: 458-70.PubMedCrossRef

38.

Gupta S, Fernandes RJ, Rao JS, Dhanpal R. Perioperative risk factors for pulmonary complications after non-cardiac surgery. J Anaesthesiol Clin Pharmacol 2020; 36: 88-93.PubMedCrossRefPubMedCentral

39.

Yang Y, Huang Y, Tang R, et al. Optimization of positive end-expiratory pressure by volumetric capnography variables in lavage-induced acute lung injury. Respiration 2014; 87: 75-83.PubMedCrossRef

Title: Difference between arterial and end-tidal carbon dioxide and adverse events after non-cardiac surgery: a historical cohort study
Authors: Ryan Davis, MD
Elizabeth Jewell, MS
Milo Engoren, MD
Michael Maile, MD
Publication date: 01-01-2022
Publisher: Springer International Publishing
Keywords: Heart Surgery
Heart Surgery
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 1/2022
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI: https://doi.org/10.1007/s12630-021-02118-8

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Difference between arterial and end-tidal carbon dioxide and adverse events after non-cardiac surgery: a historical cohort study

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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