Effects of intra-operative end-tidal carbon dioxide levels on the rates of post-operative complications in adults undergoing general anesthesia for percutaneous nephrolithotomy: A clinical trial

Mahmoud Saghaei, Gholamreza Matin, Mohammad Golparvar, Mahmoud Saghaei, Gholamreza Matin, Mohammad Golparvar

Abstract

Background: A retrospective study has shown lesser days of hospital stay in patients with increased levels of intra-operative end-tidal carbon dioxide (ETCO2). It is probable that hypercapnia may exert its beneficial effects on patients' outcome through optimization of global hemodynamic and tissue oxygenation, leading to a lower rate of post-operative complications. This study was designed to test the hypothesis that higher values of intra-operative ETCO2 decrease the rate of post-operative complications.

Materials and methods: In this randomized, double-blind clinical trial, 78 adult patients scheduled for percutaneous nephrolithotomy (PCNL) were prospectively enrolled and randomly divided into three groups. ETCO2 was set and maintained throughout the procedure at 31-33, 37-39 and 43-45 mmHg in the hypocapnia, normocapnia and hypercapnia groups, respectively. The rates of post-operative complications were compared among the three groups.

Results: Seventy-five patients completed the study (52 male and 23 female). Ten (38.5%), four (16%) and two (8.3%) patients developed post-operative vomiting in the hypocapnia, normocapnia and hypercapnia groups, respectively (P = 0.025). The nausea score was significantly lower in the hypercapnic group compared with the other groups (3.9 ± 1.8, 3.2 ± 2.1 and 1.3 ± 1.8 in the hypocapnia, normocapnia and hypercapnia groups, respectively; P = 0.000). Time to return of spontaneous respiration and awakening were significantly decreased in the hypercapnia group compared with the other groups (P < 0.01).

Conclusion: Mild intra-operative hypercapnia has a protecting effect against the development of post-operative nausea and vomiting and decreases the duration of emergence and recovery from general anesthesia.

Keywords: Carbon dioxide; hypercapnia; hypocapnia; nausea and vomiting; post-operative complications.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1
Figure 1
Study enrolment, randomization, follow-up and final analysis
Figure 2
Figure 2
Comparing the means of different emergence and recovery time intervals among the three groups. Time intervals are sequential, i.e., each time point is from a previous point. The first time interval is from discontinuation of anesthetic. Plotted data are means ± SD. *P < 0.01

References

    1. Way M, Hill GE. Intraoperative end-tidal carbon dioxide concentrations: What is the target? Anesthesiol Res Pract 2011. 2011 271539.
    1. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347–54.
    1. Mas A, Saura P, Joseph D, Blanch L, Baigorri F, Artigas A, et al. Effect of acute moderate changes in PaCO2 on global hemodynamics and gastric perfusion. Crit Care Med. 2000;28:360–5.
    1. Akça O, Liem E, Suleman MI, Doufas AG, Galandiuk S, Sessler DI. Effect of intra-operative end-tidal carbon dioxide partial pressure on tissue oxygenation. Anaesthesia. 2003;58:536–42.
    1. Akça O, Doufas AG, Morioka N, Iscoe S, Fisher J, Sessler DI. Hypercapnia improves tissue oxygenation. Anesthesiology. 2002;97:801–6.
    1. Fleischmann E, Herbst F, Kugener A, Kabon B, Niedermayr M, Sessler DI, et al. Mild hypercapnia increases subcutaneous and colonic oxygen tension in patients given 80% inspired oxygen during abdominal surgery. Anesthesiology. 2006;104:944–9.
    1. Andersen MN, Mouritzen C. Effect of acute respiratory and metabolic acidosis on cardiac output and peripheral resistance. Ann Surg. 1966;163:161–8.
    1. Walley KR, Lewis TH, Wood LD. Acute respiratory acidosis decreases left ventricular contractility but increases cardiac output in dogs. Circ Res. 1990;67:628–35.
    1. Hovorka J. Carbon dioxide homeostasis and recovery after general anaesthesia. ActaAnaesthesiolScand. 1982;26:498–504.
    1. Jhaveri RM. The effects of hypocapnic ventilation on mental function in elderly patients undergoing cataract surgery. Anaesthesia. 1989;44:635–40.
    1. Wax DB, Lin HM, Hossain S, Porter SB. Intraoperative carbon dioxide management and outcomes. Eur J Anaesthesiol. 2010;27:819–23.
    1. Baloh RW, Halmagyi GM. New York: Oxford University Press; 1996. Disorders of the Vestibular System; pp. 129–136.
    1. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: Updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c869.
    1. Saghaei M, Saghaei S. Implementation of an open-source customizable minimization program for allocation of patients to parallel groups in clinical trials. J Biomed Sci Eng. 2011;4:734–9.
    1. Cohen J. 2nd ed. Hillsdale NJ: Lawrence Erlbaum Associates; 1988. Statistical Power Analysis for the Behavioral Sciences.
    1. Akca O, Doufas AG, Morioka N, Iscoe S, Fisher J, Sessler DI. Hypercapniaimproves tissue oxygenation. Anesthesiology. 2002;97:801–6.
    1. Hickling K, Joyce C. Permissive hypercapnia in ARDS and its effects on tissue oxygenation. ActaAnaesthesiolScandSuppl. 1995;107:201–8.
    1. Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH, 3rd, Jensen JA, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. ArchSurg. 1997;132:997–1004.
    1. Jorge A, Guzman JA, Kruse JA. Splanchnic hemodynamics and gut mucosal arterial PCO(2) gradient during systemic hypocapnia. JApplPhysiol. 1999;87:1102–6.
    1. Laffey JG, Kavanagh BP. Hypocapnia. New Engl J Med. 2002;347:43–53.
    1. Johnson EE. Splanchnic hemodynamic response to passive hyperventilation. J ApplPhysiol. 1975;38:156–62.
    1. Samra S, Dy EA, Welch K, Dorje P, Zelenock GB, Stanley JC. Evaluation of a cerebral oximeter as a monitor of cerebral ischemia during carotid endarterectomy. Anesthesiology. 2000;93:964–70.
    1. Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and Carbogen intreating acute nonarteritic central retinal artery occlusion. Ophthalmology. 1995;102:2029–34.
    1. Maleki N, Alsop DC, Dai W, Hudson C, Han JS, Fisher J, et al. The effect of hypercarbia and hyperoxia on the total blood flow to the retina as assessed by magnetic resonance imaging. Invest Ophthalmol Vis Sci. 2011;52:6867–74.
    1. Apfel CC, Heidrich FM, Jukar-Rao S, Jalota L, Hornuss C, Whelan RP, et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br JAnaesth. 2012;109:742–53.
    1. Schwartz AE, Adams DC. Hypocapnia enhances the pressor effect of phenylephrine during isoflurane anesthesia in monkeys. J NeurosurgAnesthesiol. 2010;22:155–7.
    1. El-Tahan MR, Al Dossary ND, El Emam H, Diab DG, Al’Saflan A, Zien H, et al. Does hypocapnia before and during carbon dioxide insufflation attenuate the hemodynamic changes during laparoscopic cholecystectomy? SurgEndosc. 2012;26:391–7.
    1. Nishino T, Yonezawa T, Honda Y. Modification of laryngospasm in response to changes in PaCO2 and PaO2 in the cat. Anesthesiology. 1981;55:286–91.
    1. Nishino T, Hiraga K, Honda Y. Inhibitory effects of CO2 on airway defensive reflexes in enflurane-anesthetized humans. J ApplPhysiol. 1989;66:2642–6.
    1. Sasaki CT, Hundal JS, Wadie M, Woo JS, Rosenblatt W. Modulating effects of hypoxia and hypercarbia on glottic closing force. Ann OtolRhinolLaryngol. 2009;118:148–53.
    1. Nekhendzy V, Lemmens HJ, Vaughan WC, Hepworth EJ, Chiu AG, Church CA, et al. The effect of deliberate hypercapnia and hypocapnia on intraoperative blood loss and quality of surgical field during functional endoscopic sinus surgery. AnesthAnalg. 2007;105:1404–9.
    1. Lumb AB, Ito H, Kanno I, Ibaraki M, Hatazawa J, Miura S. J Cereb Blood Flow Metab. 7th ed. Vol. 23. Edinburgh: Churchill Livingstone 2010; 2003. Nunn's Applied Respiratory Physiology. Changes in human cerebral blood flow and cerebral blood volume during hypercapnia and hypocapnia measured by positron emission tomography; pp. 665–70.
    1. Vesely A, Fisher JA, Sasano N, Preiss D, Somogyi R, El-Beheiry H, et al. Isocapnic hyperpnoea accelerates recovery from isofluraneanaesthesia. Br J Anaesth. 2003;91:787–92.
    1. Katznelson R, Van Rensburg A, Friedman Z, Wasowicz M, Djaiani GN, Fedorko L, et al. Isocapnic hyperpnoea shortens postanesthetic care unit stay after isoflurane anesthesia. AnesthAnalg. 2010;111:403–8.
    1. Katznelson R, Minkovich L, Friedman Z, Fedorko L, Beattie WS, Fisher JA. Accelerated recovery from sevoflurane anesthesia with isocapnic hyperpnoea. AnesthAnalg. 2008;106:486–91.
    1. Gopalakrishnan NA, Sakata DJ, Orr JA, McJames S, Westenskow DR. Hypercapnia shortens emergence time from inhaled anesthesia in pigs. AnesthAnalg. 2007;104:815–21.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅