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Oxygenator Exhaust Capnography for Prediction of Arterial Carbon Dioxide Tension During Hypothermic Cardiopulmonary Bypass

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Oxygenator Exhaust Capnography for Prediction of Arterial Carbon Dioxide Tension During Hypothermic Cardiopulmonary Bypass JECT. 2005;37:192–195 The Journal of The American Society of Extra-Corporeal Technology Oxygenator Exhaust Capnography for Prediction of Arterial Carbon Dioxide Tension During Hypothermic Cardiopulmonary Bypass Anis Baraka, MD; Mohamad El-Khatib, PhD; Eva Muallem, MD; Salim Jamal, RN; Sania Haroun-Bizri, MD; Marie Aouad, MD Department of Anesthesiology, School of Medicine, American University of Beirut, Beirut, Lebanon Abstract: Continuous monitoring and control of arterial carbon PexCO2 and PaCO2 with a gradient of 3.4 ± 1.9 mmHg. During dioxide tension (PaCO2) during cardiopulmonary bypass (CPB) stable hypothermia, a significant correlation was obtained be- ס is essential. A reliable, accurate, and inexpensive system is not tween PexCO2 and the temperature corrected-PaCO2 (r 0.78; currently available. This study was undertaken to assess whether p < 0.05); also, there was a strong agreement between PexCO2 the continuous monitoring of oxygenator exhaust carbon dioxide and temperature corrected-PaCO2 with a gradient of 2.8 ± 2.0 tension (PexCO2) can be used to reflect PaCO2 during CPB. A mmHg. During stable hypothermia, a significant correlation was total of 33 patients undergoing CPB for cardiac surgery were obtained between PexCO2 and the temperature uncorrected- ס included in the study. During normothermia (37°C) and stable PaCO2 (r 0.61; p < 0.05); however, there was a poor agreement hypothermia (31°C), the values of PexCO2 from the oxygenator between PexCO2 and the temperature uncorrected-PaCO2 exhaust outlet were monitored and compared simultaneously with a gradient of 13.2 ± 3.8 mmHg. Oxygenator exhaust cap- with the PaCO2 values. Regression and agreement analysis were nography could be used as a mean for continuously monitoring performed between PexCO2 and temperature corrected-PaCO2 PaCO2 during normothermic phase of cardiopulmonary bypass and temperature uncorrected-PaCO2. At normothermia, a sig- as well as the temperature-corrected PaCO2 during the stable nificant correlation was obtained between PexCO2 and PaCO2 (r hypothermic phase of CPB. Keywords: exhaust capnography, .p < 0.05); there was also a strong agreement between hypothermia, cardiopulmonary bypass. JECT. 2005;37:192–195 ;0.79 ס The continuous monitoring of the membrane oxygen- study involved no alterations in routine patient manage- ator exhaust CO2 (PexCO2) has been suggested as a sub- ment, the Board waived the need for a prior informed stitute for continuous monitoring of PaCO2. However, consent. conflicting results have been reported (1,2). These con- Patients of both genders (18 men/15 women, mean age: flicting results could be attributed to the induction of hy- 64.2 ± 7.1 years, length of CPB: 50 ± 5 min) and who were pothermia and the rewarming phase of cardiopulmonary undergoing elective cardiac surgery for coronary artery bypass (CPB) (3,4), the type of oxygenator (2), the tech- bypass grafting with hemodilution hypothermic CPB using nique and site for CO2 monitoring (5,6), or the site of the alpha-stat strategy for carbon dioxide homeostasis and temperature monitoring (2). This study was undertaken to using a membrane oxygenator were included in the study. determine the validity of exhaust CO2 for the continuous Anesthesia was induced with midazolam (2 mg), thiopen- prediction of temperature-corrected versus uncorrected tone (3 mg/kg), xylocaine (2 mg/kg), sufentanyl (25 ␮g), PaCO2 during CPB using a membrane oxygenator. and rocuronium (0.6 mg/kg), to be followed by tracheal intubation and positive pressure ventilation. Anesthesia MATERIALS AND METHODS was maintained with isoflurane 1–2% in oxygen supple- mented with cisatracurium (0.15 mg/kg/h), sufentanyl (1 The study was approved by the Institutional Review ␮g/kg/h), and midazolam (0.1 ␮g/kg/min). After heparin- Board at the American University of Beirut. Because the ization (heparin of 4 mg/kg to achieve an ACT > 450 s), CPB was started using a roller pump (Sarns 8000, 3M Address correspondence to: Anis Baraka, MD, FRCA, Chairman and Health Group, Ann Arbor, MI) and a Trillium membrane Professor, Department of Anesthesiology, American University of oxygenator (Medtronic, Minneapolis, MN). Beirut, P.O. Box: 11-0236, Beirut, Lebanon, E-mail: [email protected] Nonpulsatile pump flow at 2.4 L/m2/min and a similar The senior author has stated that authors have reported no material, financial or other relationship with any healthcare-related business or oxygen flow were maintained throughout bypass. On by- other entity whose products or services are discussed in this paper. pass, hypothermia was induced by actively cooling pa- 192 EXHAUST CARBON DIOXIDE TENSION DURING CPB 193 tients down to 31°C and cold crystalloid cardioplegia was between PaCO2 and PexCO2 a sample size of at least 30 used for myocardial protection. The blood temperature patients to be included in the study. was continuously monitored with an in-line temperature probe in the CPB circuit. Hypothermia or normothermia RESULTS was defined as stable after 5–15 min of cooling or rewarm- ing with no more than ±1°C fluctuation in temperature. The mean ± standard deviation of PexCO2 and PaCO2 The oxygenator exhaust outlet of the CPB circuit was con- during normothermia (37°C) as well as the temperature- nected to a capnograph sensor (Novametrix, Willinford, corrected and temperature-uncorrected PaCO2 during CT) for continuous monitoring of exhaust CO2 (PexCO2). stable hypothermia (31°C) are presented in Table 1. A 100-cm length of anesthetic tubing was attached behind During normothermia (37°C), there was a significant ס the capnograph adaptor to act as a reservoir for the ex- positive correlation (r 0.79, p < 0.05) between PexCO2 haust gases and thus prevent entrainment of room air. The and PaCO2 (Figure 1). Also, the Bland-Altman analysis same capnograph was used on all patients throughout the revealed a strong agreement between PexCO2 and PaCO2 whole study. Before each use, it was calibrated and (Figure 2) with a gradient of 3.4 ± 1.9 mmHg (Table 2). checked using a gas containing a known concentration of During hypothermia (31°C), a similar significant posi- p < 0.05) was obtained between ,0.78 ס carbon dioxide (5% balanced with nitrogen) according to tive correlation (r the manufacturer’s instructions and was allowed to warm PexCO2 and the temperature-corrected PaCO2 (Figure 3). up for at least 1–2 h before use. All measurements were The Bland-Altman analysis also revealed a strong agree- made during full flow bypass without ejecting heart and ment between PexCO2 and the temperature-corrected mechanical ventilation (i.e., during aortic cross clamp PaCO2 (Figure 4) with a gradient of 2.8 ± 2.0 mmHg time) and no measurements were made during the cooling (Table 2). However, when the comparison was made be- and rewarming phases of the CPB. The readings of the tween PexCO2 and the temperature-uncorrected PaCO2, ס capnograph (PexCO2) were noted simultaneously with there was a decrease in the strength of correlation (r sampling of the arterial blood samples and monitoring of 0.61, p < 0.05; Figure 5) and a poor agreement as revealed the blood temperature. Arterial blood gas samples col- by the Bland-Altman analysis (Figure 6) with a gradient of lected from the oxygenator outlet and obtained on all pa- 13.2 ± 3.8 mmHg (Table 2). tients at temperatures of 31°C and 37°C were immediately subjected to duplicate measurement by a bench blood gas DISCUSSION analyzer (ABL700, Radiometer, Copenhagen, Denmark) and both temperature-corrected P CO and temperature- a 2 Close monitoring and control of PaCO2 are important uncorrected PaCO2 values were determined. The blood during all phases of CPB as carbon dioxide is the main gas analyzer was calibrated to two-point calibration im- determinant of acid-base balance and the cerebral blood mediately before starting CPB and to one-point calibra- flow (3,8). This supports the use of continuous monitoring tion every 30 min during CPB. of arterial PaCO2during normothermic and hypothermic CPB. However, in-line continuous monitoring of PaCO2 is Statistical Analysis expensive and prone to errors particularly when used for long duration (5,6). The means and standard deviations of exhaust PCO2 Our results showed that during CPB using a membrane (PexCO2), temperature-corrected PaCO2, and tempera- oxygenator, there is a strong agreement between arterial ture-uncorrected PaCO2 were obtained at 31°C and 37°C. Also, the means and standard deviations of the gradients and exhaust carbon dioxide tensions at normothermia. During hypothermia a similar strong agreement was ob- between PexCO2 and PaCO2 at 37°C and between served between temperature-corrected arterial carbon di- PexCO2 and temperature-corrected and temperature- oxide and exhaust carbon dioxide tensions; however, a uncorrected PaCO2 at 31°C were obtained. These mean values were compared with the Student’s t test and the analysis of variance. The degrees of correlation between Table 1. Mean ± SD (mmHg) of PexCO2,PaCO2, temperature- corrected P CO , and temperature-uncorrected P CO at nor- PexCO2 and the temperature-corrected PaCO2 and tem- a 2 a 2 mothermia (37°C) and during stable hypothermia (31°C). perature-uncorrected PaCO2 were determined by regres- sion analysis. Also, the degree of agreement between Temperature- Temperature- Corrected Uncorrected PexCO2 and the temperature-corrected PaCO2 and tem- n PexCO2 PaCO2 PaCO2 PaCO2 perature-uncorrected-PaCO2 were determined with the Bland-Altman analysis (7). Statistical significance was 37°C 30 33.9 ± 3.1 37.1 ± 2.9* N/A N/A considered at p < 0.05. 31°C 33 26.3 ± 2.9 N/A 29.0 ± 3.0* 39.4 ± 4.8* A power analysis using a Type I error of 5% and Type *p < 0.05 vs. PexCO2. II error of 80% indicated that for a non-significant bias N/A, not applicable.
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