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Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study.

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.

SUBMITTER: Fuller BM

PROVIDER: S-EPMC5633513 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study.

Fuller Brian M BM Mohr Nicholas M NM Drewry Anne M AM Ferguson Ian T IT Trzeciak Stephen S Kollef Marin H MH Roberts Brian W BW

Journal of critical care 20170426

<h4>Purpose</h4>To describe the prevalence of hypocapnia and hypercapnia during the earliest period of mechanical ventilation, and determine the association between P<sub>a</sub>CO<sub>2</sub> and mortality.<h4>Materials and methods</h4>A cohort study using an emergency department registry of mechanically ventilated patients. P<sub>a</sub>CO<sub>2</sub> was categorized: hypocapnia (<35mmHg), normocapnia (35-45mmHg), and hypercapnia (>45mmHg). The primary outcome was survival to hospital discharg ...[more]

PMID: 28472700

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Project description:OBJECTIVE:The objective of this study was to test the association between the partial pressure of arterial carbon dioxide and survival to hospital discharge among mechanically ventilated patients diagnosed with sepsis in the emergency department. DESIGN:Retrospective cohort study of a single center trial registry. SETTING:Academic medical center. PATIENTS:Mechanically ventilated emergency department patients. INCLUSION CRITERIA:age 18 years and older, diagnosed with sepsis in the emergency department, and mechanical ventilation initiated in the emergency department. INTERVENTIONS:Arterial blood gases obtained after initiation of mechanical ventilation were analyzed. The primary outcome was survival to hospital discharge. We tested the association between partial pressure of arterial carbon dioxide and survival using multivariable logistic regression adjusting for potential confounders. Sensitivity analyses, including propensity score matching were also performed. MEASUREMENTS AND MAIN RESULTS:Six hundred subjects were included, and 429 (72%) survived to hospital discharge. The median (interquartile range) partial pressure of arterial carbon dioxide was 42 (34-53) mm Hg for the entire cohort and 44 (35-57) and 39 (31-45) mm Hg among survivors and nonsurvivors, respectively (p < 0.0001 Wilcox rank-sum test). On multivariable analysis, a 1?mm Hg rise in partial pressure of arterial carbon dioxide was associated with a 3% increase in odds of survival (adjusted odds ratio, 1.03; 95% CI, 1.01-1.04) after adjusting for tidal volume and other potential confounders. These results remained significant on all sensitivity analyses. CONCLUSION:In this sample of mechanically ventilated sepsis patients, we found an association between increasing levels of partial pressure of arterial carbon dioxide and survival to hospital discharge. These findings justify future studies to determine the optimal target partial pressure of arterial carbon dioxide range for mechanically ventilated sepsis patients.

Project description:OBJECTIVE:To evaluate the prognostic value of the difference between peripheral venous and arterial partial pressure of carbon dioxide in patients with septic shock following early resuscitation. METHODS:This prospective study was conducted among the patients with septic shock treated in our department during the period from May, 2017 to May, 2018. Peripheral venous, peripheral arterial and central venous blood samples were collected simultaneously and analyzed immediately at bedside after 6-h bundle treatment. Arterial blood lactate concentration (Lac) and the arterial (PaCO2), peripheral venous (PpvCO2) and central venous partial pressure of carbon dioxide (PcvCO2) were recorded. The differences between PpvCO2 and PaCO2 (Ppv-aCO2) and between PcvCO2 and PaCO2 (Pcv-aCO2) were calculated. Pearson correlation analysis was used to test the agreement between Pcv-aCO2 and Ppv-aCO2. Multivariable logistic regression analysis was performed to analyze the possible risk factors for 28-day mortality, and the receiver-operating characteristic curve (ROC) was plotted to assess the prognostic values of these factors for 28-day mortality. RESULTS:A total of 62 patients were enrolled in this study, among who 35 survived and 27 died during the 28-day period. Compared with the survivor group, the patients died within 28 days showed significantly higher Acute Physiology and Chronic Health Evaluation ? (APACHE ?) score (24.2±6.0 vs 20.5±4.9, P=0.011), sequential organ failure assessment (SOFA) score (14.9±4.7 vs 12.2±4.5, P=0.027), PcvaCO2 (5.5±1.6 vs 7.1±1.7, P < 0.001), PpvaCO2 (7.1±1.8 vs 10.0±2.7, P < 0.001), and arterial lactate level (3.3±1.2 vs 4.2±1.3, P=0.003) after 6-h bundle treatment. Pearson correlation analysis showed that Ppv-aCO2 was significantly correlated with Pcv-aCO2 (r=0.897, R2= 0.805, P < 0.001). Multiple logistic regression analysis identified Ppv-aCO2 (?=0.625, P=0.001, OR=1.869, 95% CI: 1.311-2.664) and lactate level (?=0.584, P=0.041, OR=1.794, 95%CI: 1.024-3.415) as the independent risk factors for 28-day mortality. The maximum area under the ROC (AUC) of Ppv-aCO2 was 0.814 (95%CI: 0.696- 0.931, P < 0.001), and at the best cut- off value of 9.05 mmHg, Ppv-aCO2 had a sensitivity of 70.4% and a specificity of 88.6% for predicting 28-day mortality. The AUC of lactate level was 0.732 (95%CI: 0.607-0.858, P=0.002), and its sensitivity for predicting 28-day mortality was 70.4% and the specificity was 74.3% at the best cut-off value of 3.45 mmol/L; The AUC of Pcv-aCO2 was 0.766 (95%CI: 0.642-0.891, P < 0.001), and its sensitivity was 66.7% and the specificity was 80.0% at the best cut-off value of 7.05 mmHg. CONCLUSIONS:A high Ppv-aCO2 after early resuscitation of septic shock is associated with poor outcomes. Ppv-aCO2 is well correlated with Pcv-aCO2 and can be used as an independent indicator for predicting 28-day mortality in patients with septic shock.

Project description:Background:Tidal hyperinflation can still occur with mechanical ventilation using low tidal volume (LVT) (6?mL/kg predicted body weight (PBW)) in acute respiratory distress syndrome (ARDS), despite a well-demonstrated reduction in mortality. Methods:Retrospective chart review from August 2012 to October 2014. Inclusion: Age >18years, PaO2/FiO2<200 with bilateral pulmonary infiltrates, absent heart failure, and ultra-protective mechanical ventilation (UPMV) defined as tidal volume (VT) <6?mL/kg PBW. Exclusion: UPMV use for <24?h. Demographics, admission Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, arterial blood gas, serum bicarbonate, ventilator parameters for pre-, during, and post-UPMV periods including modes, VT, peak inspiratory pressure (PIP), plateau pressure (Pplat), driving pressure, etc. were gathered. We compared lab and ventilator data for pre-, during, and post-UPMV periods. Results:Fifteen patients (male:female?=?7:8, age 42.13?±?11.29 years) satisfied criteria, APACHEII 20.6?±?7.1, mean days in intensive care unit and hospitalization were 18.5?±?8.85 and 20.81?±?9.78 days, 9 (60%) received paralysis and 7 (46.67%) required inotropes. Eleven patients had echocardiogram, 7 (63.64%) demonstrated right ventricular volume or pressure overload. Eleven patients (73.33%) survived. During-UPMV, VT ranged 2-5?mL/kg PBW(3.99?±?0.73), the arterial partial pressure of carbon dioxide (PaCO2) was higher than pre-UPMV values (84.81?±?18.95 cmH2O vs. 69.16?±?33.09 cmH2O), but pH was comparable and none received extracorporeal carbon dioxide removal (ECCO2-R). The positive end-expiratory pressure (14.18?±?7.56 vs. 12.31?±?6.84 cmH2O), PIP (38.21?±?12.89 vs. 32.59?±?9.88), and mean airway pressures (19.98?±?7.61 vs. 17.48?±?6.7?cm H2O) were higher during UPMV, but Pplat and PaO2/FiO2 were comparable during- and pre-UPMV. Driving pressure was observed to be higher in those who died than who survived (24.18?±?12.36 vs. 13.42?±?3.25). Conclusion:UPMV alone may be a safe alternative option for ARDS patients in centers without ECCO2-R.

Dataset Information

Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study.

Publications

Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study.

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