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

Authors

Department of Anesthesia, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Background: A retrospective study has shown lesser days of hospital stay in patients with increased levels of intra-operative end-tidal carbon dioxide (ETCO 2 ). 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 ETCO 2 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. ETCO 2 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

1. Way M, Hill GE. Intraoperative end-tidal carbon dioxide concentrations: What is the target? Anesthesiol Res Pract 2011;2011:271539.   Back to cited text no. 1
    
2. 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.  Back to cited text no. 2
    
3. 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.  Back to cited text no. 3
    
4. 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.  Back to cited text no. 4
    
5. Akça O, Doufas AG, Morioka N, Iscoe S, Fisher J, Sessler DI. Hypercapnia improves tissue oxygenation. Anesthesiology 2002;97:801-6.  Back to cited text no. 5
    
6. 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.  Back to cited text no. 6
    
7. Andersen MN, Mouritzen C. Effect of acute respiratory and metabolic acidosis on cardiac output and peripheral resistance. Ann Surg 1966;163:161-8.  Back to cited text no. 7
    
8. 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.  Back to cited text no. 8
    
9. Hovorka J. Carbon dioxide homeostasis and recovery after general anaesthesia. ActaAnaesthesiolScand 1982;26:498-504.  Back to cited text no. 9
    
10. Jhaveri RM. The effects of hypocapnic ventilation on mental function in elderly patients undergoing cataract surgery. Anaesthesia 1989;44:635-40.  Back to cited text no. 10
    
11. Wax DB, Lin HM, Hossain S, Porter SB. Intraoperative carbon dioxide management and outcomes. Eur J Anaesthesiol 2010;27:819-23.  Back to cited text no. 11
    
12. Baloh RW, Halmagyi GM. Disorders of the Vestibular System. New York: Oxford University Press; 1996.129-136.  Back to cited text no. 12
    
13. 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.  Back to cited text no. 13
    
14. 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.  Back to cited text no. 14
    
15. Cohen J. In: Statistical Power Analysis for the Behavioral Sciences. 2nd ed. HillsdaleNJ.: Lawrence Erlbaum Associates; 1988.  Back to cited text no. 15
    
16. Akca O, Doufas AG, Morioka N, Iscoe S, Fisher J, Sessler DI. Hypercapniaimproves tissue oxygenation. Anesthesiology 2002;97:801-6.  Back to cited text no. 16
    
17. Hickling K, Joyce C. Permissive hypercapnia in ARDS and its effects on tissue oxygenation. ActaAnaesthesiolScandSuppl 1995;107:201-8.  Back to cited text no. 17
    
18. 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.  Back to cited text no. 18
    
19. Jorge A, Guzman JA, Kruse JA. Splanchnic hemodynamics and gut mucosal arterial PCO(2) gradient during systemic hypocapnia. JApplPhysiol 1999;87:1102-6.  Back to cited text no. 19
    
20. Laffey JG, Kavanagh BP. Hypocapnia. New Engl J Med 2002;347:43-53.  Back to cited text no. 20
    
21. Johnson EE. Splanchnic hemodynamic response to passive hyperventilation. J ApplPhysiol 1975;38:156-62.  Back to cited text no. 21
    
22. 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.  Back to cited text no. 22
    
23. 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.  Back to cited text no. 23
    
24. 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.  Back to cited text no. 24
    
25. 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.  Back to cited text no. 25
    
26. Schwartz AE, Adams DC. Hypocapnia enhances the pressor effect of phenylephrine during isoflurane anesthesia in monkeys. J NeurosurgAnesthesiol 2010;22:155-7.  Back to cited text no. 26
    
27. 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.  Back to cited text no. 27
    
28. 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.  Back to cited text no. 28
    
29. Nishino T, Hiraga K, Honda Y. Inhibitory effects of CO2 on airway defensive reflexes in enflurane-anesthetized humans. J ApplPhysiol 1989;66:2642-6.  Back to cited text no. 29
    
30. 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.  Back to cited text no. 30
    
31. 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.  Back to cited text no. 31
    
32. Lumb AB. In: Nunn's Applied Respiratory Physiology. 7th ed. Edinburgh: Churchill Livingstone; 2010.: Ito H, Kanno I, Ibaraki M, Hatazawa J, Miura S. Changes in human cerebral blood flow and cerebral blood volume during hypercapnia and hypocapnia measured by positron emission tomography. J Cereb Blood Flow Metab 2003;23:665-70.  Back to cited text no. 32
    
33. 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.  Back to cited text no. 33
    
34. 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.  Back to cited text no. 34
    
35. 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.  Back to cited text no. 35
    
36. Gopalakrishnan NA, Sakata DJ, Orr JA, McJames S, Westenskow DR. Hypercapnia shortens emergence time from inhaled anesthesia in pigs. AnesthAnalg 2007;104:815-21.  Back to cited text no. 36