Hypocapnia measured by end-tidal carbon dioxide tension during anesthesia is associated with increased 30-day mortality rate

Dony, Philippe; Dramaix, M.; Boogaerts, Jean G.

doi:10.1016/j.jclinane.2016.10.028

Cited by 22 publications

(19 citation statements)

References 18 publications

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“…Where simultaneous assessments of arterial and end-tidal CO 2 were compared our results indicate a good correlation with a stable bias over the range of CO 2 values examined. The important corroborating study by Dony et al ( 15 ) indicating worse outcome with hypocapnic end-tidal CO 2 is noted. Finally, POD and POD severity were only assessed once daily at a time of convenience, which might not accurately represent the full spectrum of POD as it presents with a fluctuating course.…”

Section: Discussionsupporting

confidence: 77%

“…An older literature, some dating back over 50 years, has indicated that pronounced intraoperative hypocapnia (more severe than examined here) can impair some indices of cognitive performance postoperatively ( 26 – 28 ). A large retrospective study by Dony et al ( 15 ) indicates that intraoperative hypocapnia is associated with greater length of stay and greater 30 day mortality after non-cardiac surgery in adults. Their study in 5317 patients indicated that nearly 2/3 patients were hypocapnic by their criteria (end-tidal CO 2 < 4.7 kPa) at a mean end-tidal CO 2 the same as described here (4.4 kPa).…”

Section: Discussionmentioning

confidence: 99%

“…( 11 , 13 , 14 ), In this context intracranial steal is a potential causal risk for POD. A large retrospective study indicated that hypocapnia, as determined by intraoperative measurement of end-tidal CO 2 , is associated with hospital length of stay and 30-day postoperative mortality ( 15 ). Their work suggests that perioperative ventilatory management as assessed by end-tidal CO 2 can be predictive of patient outcome.…”

Section: Introductionmentioning

confidence: 99%

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End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium

et al. 2018

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Background: Postoperative delirium (POD) might be associated with anesthetic management, but research has focused on choice or dosage of anesthetic drugs. We examined potential contributions of intraoperative ventilatory and hemodynamic management to POD.Methods: This was a sub-study of the ENGAGES-Canada trial (NCT02692300) involving non-cardiac surgery patients enrolled in Winnipeg, Canada. Patients received preoperative psychiatric and cognitive assessments, and intraoperatively underwent high-fidelity data collection of blood pressure, end-tidal respiratory gases and anesthetic agent concentration. POD was assessed by peak and mean POD scores using the Confusion Assessment Method-Severity (CAM-S) tool. Bivariate and multiple linear regression models were constructed controlling for age, psychiatric illness, and cognitive dysfunction in the examination of deviations in intraoperative end-tidal carbon dioxide (areas over (AOC) and under the curve (AUC)) on POD severity scores.Results: A total of 101 subjects [69 (6) years of age] were studied; 89 had comprehensive intraoperative hemodynamic and end-tidal gas measurements (data recorded at 1 Hz). The incidence of POD was 11.9% (12/101). Age, cognitive dysfunction, anxiety, depression, and intraoperative end-tidal CO2 (AUC) were significant correlates of POD severity. In the multiple regression model, cognitive dysfunction and AUC end-tidal CO2 (0.67 kPa below median intra-operative value) were the only independent significant predictors across both POD severity (mean and peak) scores. There was no association between cumulative anesthetic agent exposure and POD.Conclusions: POD was associated with intraoperative ventilatory management, reflected by low end-tidal CO2 concentrations, but not with cumulative anesthetic drug exposure. These findings suggest that maintenance of intraoperative normocapnia might benefit patients at risk of POD.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium

et al. 2018

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“…Nevertheless, there is no good evidence to support the benefit of hypocapnia, and some studies suggest benefits for higher ETCO 2 levels. 1 , 4 , 5 First, it is easier to implement low tidal volume ventilation. 6 , 7 Second, hypercapnia increases the cardiac output, resulting in an increase in tissue oxygenation, which in turn may prevent surgical site infections.…”

mentioning

confidence: 99%

“…Unfortunately, many studies focus on the critical care population, leaving surgical patients underrepresented. 1 , 2 , 4 , 5 , 8 - 10 Therefore, there is no strong evidence of a benefit for higher CO 2 tensions compared with hypocapnia in perioperative patients.…”

mentioning

confidence: 99%

An observational study of end-tidal carbon dioxide trends in general anesthesia

Akkermans

Waes

Thompson

et al. 2018

Can J Anesth/J Can Anesth

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PurposeDespite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO2) levels in surgical patients, there is still insufficient data to formulate guidelines for ideal intraoperative ETCO2 targets. As it is unclear which intraoperative ETCO2 levels are currently used and whether these levels have changed over time, we investigated the practice pattern using the Multicenter Perioperative Outcomes Group database.MethodsThis retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016. The primary outcome was a time-weighted average area-under-the-curve (TWA-AUC) for four ETCO2 thresholds (< 28, < 35, < 45, and > 45 mmHg). Additionally, a median ETCO2 was studied. A Kruskal-Wallis test was used to analyse differences between years. Random-effect multivariable logistic regression models were constructed to study variability.ResultsBoth TWA-AUC and median ETCO2 showed a minimal increase in ETCO2 over time, with a median [interquartile range] ETCO2 of 33 [31.0–35.0] mmHg in 2008 and 35 [33.0–38.0] mmHg in 2016 (P <0.001). A large inter-hospital and inter-provider variability in ETCO2 were observed after adjustment for patient characteristics, ventilation parameters, and intraoperative blood pressure (intraclass correlation coefficient 0.36; 95% confidence interval, 0.18 to 0.58).ConclusionsBetween 2008 and 2016, intraoperative ETCO2 values did not change in a clinically important manner. Interestingly, we found a large inter-hospital and inter-provider variability in ETCO2 throughout the study period, possibly indicating a broad range of tolerance for ETCO2, or a lack of evidence to support a specific targeted range. Clinical outcomes were not assessed in this study and they should be the focus of future research.Electronic supplementary materialThe online version of this article (10.1007/s12630-018-1249-1) contains supplementary material, which is available to authorized users.

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