Volumetric and End-Tidal Capnography for the Detection of Cardiac Output Changes in Mechanically Ventilated Patients Early after Open Heart Surgery

Ingrid Elise Hoff, Lars Øivind Høiseth, Knut Arvid Kirkebøen, Svein Aslak Landsverk, Ingrid Elise Hoff, Lars Øivind Høiseth, Knut Arvid Kirkebøen, Svein Aslak Landsverk

Abstract

Background: Exhaled carbon dioxide (CO2) reflects cardiac output (CO) provided stable ventilation and metabolism. Detecting CO changes may help distinguish hypovolemia or cardiac dysfunction from other causes of haemodynamic instability. We investigated whether CO2 measured as end-tidal concentration (EtCO2) and eliminated volume per breath (VtCO2) reflect sudden changes in cardiac output (CO).

Methods: We measured changes in CO, VtCO2, and EtCO2 during right ventricular pacing and passive leg raise in 33 ventilated patients after open heart surgery. CO was measured with oesophageal Doppler.

Results: During right ventricular pacing, CO was reduced by 21% (CI 18-24; p < 0.001), VtCO2 by 11% (CI 7.9-13; p < 0.001), and EtCO2 by 4.9% (CI 3.6-6.1; p < 0.001). During passive leg raise, CO increased by 21% (CI 17-24; p < 0.001), VtCO2 by 10% (CI 7.8-12; p < 0.001), and EtCO2 by 4.2% (CI 3.2-5.1; p < 0.001). Changes in VtCO2 were significantly larger than changes in EtCO2 (ventricular pacing: 11% vs. 4.9% (p < 0.001); passive leg raise: 10% vs. 4.2% (p < 0.001)). Relative changes in CO correlated with changes in VtCO2 (ρ=0.53; p=0.002) and EtCO2 (ρ=0.47; p=0.006) only during reductions in CO. When dichotomising CO changes at 15%, only EtCO2 detected a CO change as judged by area under the receiver operating characteristic curve.

Conclusion: VtCO2 and EtCO2 reflected reductions in cardiac output, although correlations were modest. The changes in VtCO2 were larger than the changes in EtCO2, but only EtCO2 detected CO reduction as judged by receiver operating characteristic curves. The predictive ability of EtCO2 in this setting was fair. This trial is registered with NCT02070861.

Figures

Figure 1
Figure 1
Study protocol. Sixty-second baseline measurements before 30 s of RVP and 60 s of PLR. The sequence of the interventions varied, minimum 5 min apart.
Figure 2
Figure 2
Flow chart inclusion.
Figure 3
Figure 3
Lineplot. Individual (grey) and mean (black) values with 95% confidence intervals for CO, VtCO2, and EtCO2 before, during, and after interventions. CO = cardiac output; EtCO2 = end-tidal carbon dioxide; VtCO2 = exhaled carbon dioxide per tidal volume; BL = baseline; RVP = right ventricular pacing; PLR = passive leg raise.
Figure 4
Figure 4
Scatterplot EtCO2. Correlation between mean relative changes in CO and EtCO2 from BL to RVP and PLR, respectively. Least significant changes for CO and EtCO2 are indicated with shadows. CO = cardiac output; EtCO2 = end-tidal carbon dioxide; VtCO2 = exhaled carbon dioxide per tidal volume; BL = baseline; RVP = right ventricular pacing; PLR = passive leg raise; ρ = Spearman's rho with confidence intervals.
Figure 5
Figure 5
Correlation between mean relative changes in CO and VtCO2 from BL to RVP and PLR, respectively. Least significant changes for CO and VtCO2 are indicated with shadows. Dots are for RVP; circles are for PLR. CO = cardiac output; EtCO2 = end-tidal carbon dioxide; VtCO2 = exhaled carbon dioxide per tidal volume; BL = baseline; RVP = right ventricular pacing; PLR = passive leg raise; ρ = Spearman's rho with confidence intervals.
Figure 6
Figure 6
ROC-plot. Receiver operating characteristic plots of VtCO2 and EtCO2 during right ventricular pacing and passive leg raise, respectively. EtCO2 = end-tidal carbon dioxide; VtCO2 = exhaled carbon dioxide per tidal volume; AUC = area under the curve.

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