Association of intraoperative end-tidal CO2 levels with postoperative outcomes: a patient-level analysis of two randomised clinical trials
Issued Date
2025-01-01
Resource Type
ISSN
00070912
eISSN
14716771
Scopus ID
2-s2.0-105015599329
Pubmed ID
40930872
Journal Title
British Journal of Anaesthesia
Rights Holder(s)
SCOPUS
Bibliographic Citation
British Journal of Anaesthesia (2025)
Suggested Citation
Nasa P., van Meenen D.M.P., Paulus F., Ferrando C., Bluth T., Gama de Abreu M., Ball L., Bossers S.M., Schober P., Schultz M.J., Serpa Neto A., Hemmes S.N.T., Campos N.S., Bluth T., Hemmes S.N.T., Librero J., Pozo N., Ferrando C., Ball L., Mazzinari G., Pelosi P., Gama de Abreu M., Schultz M.J., Neto A.S., Hemmes S.N.T., Gama de Abreu M., Severgnini P., Hollmann M.W., Binnekade J.M., Wrigge H., Canet J., Hiesmayr M., Schmid W., Tschernko E., Jaber S., Hedenstierna G., Putensen C., Pelosi P., Schultz M.J., Marti A., Bacuzzi A., Brodhun A., Molin A., Merten A., Parera A., Brunelli A., Cortegiani A., Güldner A., Reske A.W., Gratarola A., Giarratano A., Bastin B., Heyse B., Mazul-Sunko B., Amantea B., Barberis B., Putensen C., Uhlig C., Marín C.M., Celentano C., La Bella D., D'Antini D., Velghe D., Sulemanji D., De Robertis E., Hartmann E., Montalto F., Tropea F., Mills G.H., Cinnella G., Della Rocca G., Caggianelli G., Pellerano G., Mollica G., Bugedo G., Wrigge H., Mulier J.P., Vandenbrande J., Geib J., Yaqub J., Florez J., Mayoral J.F., Sprung J., Van Limmen J., Bos L.D.J., de Baerdemaeker L., Jamaer L., Spagnolo L., Strys L., Gil M.G., Gama de Abreu M., Vidal Melo M.F., Schultz M.J., Unzueta M.C., Moral M.V., Ferner M., Hollmann M.W., Weiss M., Vanoni M., Schaefer M.S. Association of intraoperative end-tidal CO2 levels with postoperative outcomes: a patient-level analysis of two randomised clinical trials. British Journal of Anaesthesia (2025). doi:10.1016/j.bja.2025.07.076 Retrieved from: https://repository.li.mahidol.ac.th/handle/123456789/112115
Title
Association of intraoperative end-tidal CO2 levels with postoperative outcomes: a patient-level analysis of two randomised clinical trials
Author(s)
Nasa P.
van Meenen D.M.P.
Paulus F.
Ferrando C.
Bluth T.
Gama de Abreu M.
Ball L.
Bossers S.M.
Schober P.
Schultz M.J.
Serpa Neto A.
Hemmes S.N.T.
Campos N.S.
Bluth T.
Hemmes S.N.T.
Librero J.
Pozo N.
Ferrando C.
Ball L.
Mazzinari G.
Pelosi P.
Gama de Abreu M.
Schultz M.J.
Neto A.S.
Hemmes S.N.T.
Gama de Abreu M.
Severgnini P.
Hollmann M.W.
Binnekade J.M.
Wrigge H.
Canet J.
Hiesmayr M.
Schmid W.
Tschernko E.
Jaber S.
Hedenstierna G.
Putensen C.
Pelosi P.
Schultz M.J.
Marti A.
Bacuzzi A.
Brodhun A.
Molin A.
Merten A.
Parera A.
Brunelli A.
Cortegiani A.
Güldner A.
Reske A.W.
Gratarola A.
Giarratano A.
Bastin B.
Heyse B.
Mazul-Sunko B.
Amantea B.
Barberis B.
Putensen C.
Uhlig C.
Marín C.M.
Celentano C.
La Bella D.
D'Antini D.
Velghe D.
Sulemanji D.
De Robertis E.
Hartmann E.
Montalto F.
Tropea F.
Mills G.H.
Cinnella G.
Della Rocca G.
Caggianelli G.
Pellerano G.
Mollica G.
Bugedo G.
Wrigge H.
Mulier J.P.
Vandenbrande J.
Geib J.
Yaqub J.
Florez J.
Mayoral J.F.
Sprung J.
Van Limmen J.
Bos L.D.J.
de Baerdemaeker L.
Jamaer L.
Spagnolo L.
Strys L.
Gil M.G.
Gama de Abreu M.
Vidal Melo M.F.
Schultz M.J.
Unzueta M.C.
Moral M.V.
Ferner M.
Hollmann M.W.
Weiss M.
Vanoni M.
Schaefer M.S.
van Meenen D.M.P.
Paulus F.
Ferrando C.
Bluth T.
Gama de Abreu M.
Ball L.
Bossers S.M.
Schober P.
Schultz M.J.
Serpa Neto A.
Hemmes S.N.T.
Campos N.S.
Bluth T.
Hemmes S.N.T.
Librero J.
Pozo N.
Ferrando C.
Ball L.
Mazzinari G.
Pelosi P.
Gama de Abreu M.
Schultz M.J.
Neto A.S.
Hemmes S.N.T.
Gama de Abreu M.
Severgnini P.
Hollmann M.W.
Binnekade J.M.
Wrigge H.
Canet J.
Hiesmayr M.
Schmid W.
Tschernko E.
Jaber S.
Hedenstierna G.
Putensen C.
Pelosi P.
Schultz M.J.
Marti A.
Bacuzzi A.
Brodhun A.
Molin A.
Merten A.
Parera A.
Brunelli A.
Cortegiani A.
Güldner A.
Reske A.W.
Gratarola A.
Giarratano A.
Bastin B.
Heyse B.
Mazul-Sunko B.
Amantea B.
Barberis B.
Putensen C.
Uhlig C.
Marín C.M.
Celentano C.
La Bella D.
D'Antini D.
Velghe D.
Sulemanji D.
De Robertis E.
Hartmann E.
Montalto F.
Tropea F.
Mills G.H.
Cinnella G.
Della Rocca G.
Caggianelli G.
Pellerano G.
Mollica G.
Bugedo G.
Wrigge H.
Mulier J.P.
Vandenbrande J.
Geib J.
Yaqub J.
Florez J.
Mayoral J.F.
Sprung J.
Van Limmen J.
Bos L.D.J.
de Baerdemaeker L.
Jamaer L.
Spagnolo L.
Strys L.
Gil M.G.
Gama de Abreu M.
Vidal Melo M.F.
Schultz M.J.
Unzueta M.C.
Moral M.V.
Ferner M.
Hollmann M.W.
Weiss M.
Vanoni M.
Schaefer M.S.
Author's Affiliation
Monash University
Cleveland Clinic Foundation
Amsterdam UMC - University of Amsterdam
Medizinische Universität Wien
Hospital Clínic de Barcelona
IRCCS San Martino Polyclinic Hospital
Nuffield Department of Medicine
Universitätsklinikum Carl Gustav Carus Dresden
Centro de Investigación Biomédica en Red de Enfermedades Respiratorias
Hospital Israelita Albert Einstein
Antoni van Leeuwenhoek Ziekenhuis
Melbourne Medical School
Mahidol Oxford Tropical Medicine Research Unit
New Cross Hospital
Helicopter Emergency Medical Service Lifeliner 1
Cleveland Clinic Foundation
Amsterdam UMC - University of Amsterdam
Medizinische Universität Wien
Hospital Clínic de Barcelona
IRCCS San Martino Polyclinic Hospital
Nuffield Department of Medicine
Universitätsklinikum Carl Gustav Carus Dresden
Centro de Investigación Biomédica en Red de Enfermedades Respiratorias
Hospital Israelita Albert Einstein
Antoni van Leeuwenhoek Ziekenhuis
Melbourne Medical School
Mahidol Oxford Tropical Medicine Research Unit
New Cross Hospital
Helicopter Emergency Medical Service Lifeliner 1
Corresponding Author(s)
Other Contributor(s)
Abstract
Background: The relationship between intraoperative end-tidal CO<inf>2</inf> (etCO<inf>2</inf>) levels and postoperative outcomes remains unclear. We conducted a post hoc analysis of two randomised trials in adults undergoing major surgery under general anaesthesia. Methods: We re-analysed individual participant data comparing high or low positive end-expiratory pressure with low tidal volume intraoperative ventilation using a merged database derived from two randomised trials in non-obese (PROVHILO: ISRCTN70332574) and obese (PROBESE: NCT02148692) patients. The exposure of interest was low etCO<inf>2</inf> (<4.7 kPa) vs normal-high etCO<inf>2</inf> (≥4.7 kPa). The primary outcome was postoperative pulmonary complications within 5 days. A time-weighted etCO<inf>2</inf> analysis and propensity score matching were also performed to adjust for confounding. Results: Of 2793 participants, 891 (29.4%; 52% female) had low etCO<inf>2</inf>, compared with 1972/2793 (70.6%; 65% female) participants with normal-high etCO<inf>2</inf>. Compared with participants with normal-high etCO<inf>2</inf>, higher minute volumes (normalised to body weight) were delivered in participants with low etCO<inf>2</inf>. Postoperative pulmonary complications developed in 278/821 (34%) participants with low etCO<inf>2</inf>, compared with 462/1972 (23%) participants who had normal-high etCO<inf>2</inf> (adjusted hazard ratio, 1.3; 95% confidence interval, 1.1–1.6; P<0.001). The time-weighted analysis showed an inverse linear relationship between the mean etCO<inf>2</inf> and postoperative pulmonary complications, which was also confirmed by propensity matching. Conclusions: Low etCO<inf>2</inf> occurs often during intraoperative ventilation and is associated with a higher rate of PPCs. The etCO<inf>2</inf> level has an inverse dose-dependent relationship with postoperative pulmonary complications. Clinical trial registration: NCT05550181.