Association of intraoperative end-tidal CO2 levels with postoperative outcomes: a patient-level analysis of two randomised clinical trials

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dc.contributor.authorNasa P.
dc.contributor.authorvan Meenen D.M.P.
dc.contributor.authorPaulus F.
dc.contributor.authorFerrando C.
dc.contributor.authorBluth T.
dc.contributor.authorGama de Abreu M.
dc.contributor.authorBall L.
dc.contributor.authorBossers S.M.
dc.contributor.authorSchober P.
dc.contributor.authorSchultz M.J.
dc.contributor.authorSerpa Neto A.
dc.contributor.authorHemmes S.N.T.
dc.contributor.authorCampos N.S.
dc.contributor.authorBluth T.
dc.contributor.authorHemmes S.N.T.
dc.contributor.authorLibrero J.
dc.contributor.authorPozo N.
dc.contributor.authorFerrando C.
dc.contributor.authorBall L.
dc.contributor.authorMazzinari G.
dc.contributor.authorPelosi P.
dc.contributor.authorGama de Abreu M.
dc.contributor.authorSchultz M.J.
dc.contributor.authorNeto A.S.
dc.contributor.authorHemmes S.N.T.
dc.contributor.authorGama de Abreu M.
dc.contributor.authorSevergnini P.
dc.contributor.authorHollmann M.W.
dc.contributor.authorBinnekade J.M.
dc.contributor.authorWrigge H.
dc.contributor.authorCanet J.
dc.contributor.authorHiesmayr M.
dc.contributor.authorSchmid W.
dc.contributor.authorTschernko E.
dc.contributor.authorJaber S.
dc.contributor.authorHedenstierna G.
dc.contributor.authorPutensen C.
dc.contributor.authorPelosi P.
dc.contributor.authorSchultz M.J.
dc.contributor.authorMarti A.
dc.contributor.authorBacuzzi A.
dc.contributor.authorBrodhun A.
dc.contributor.authorMolin A.
dc.contributor.authorMerten A.
dc.contributor.authorParera A.
dc.contributor.authorBrunelli A.
dc.contributor.authorCortegiani A.
dc.contributor.authorGüldner A.
dc.contributor.authorReske A.W.
dc.contributor.authorGratarola A.
dc.contributor.authorGiarratano A.
dc.contributor.authorBastin B.
dc.contributor.authorHeyse B.
dc.contributor.authorMazul-Sunko B.
dc.contributor.authorAmantea B.
dc.contributor.authorBarberis B.
dc.contributor.authorPutensen C.
dc.contributor.authorUhlig C.
dc.contributor.authorMarín C.M.
dc.contributor.authorCelentano C.
dc.contributor.authorLa Bella D.
dc.contributor.authorD'Antini D.
dc.contributor.authorVelghe D.
dc.contributor.authorSulemanji D.
dc.contributor.authorDe Robertis E.
dc.contributor.authorHartmann E.
dc.contributor.authorMontalto F.
dc.contributor.authorTropea F.
dc.contributor.authorMills G.H.
dc.contributor.authorCinnella G.
dc.contributor.authorDella Rocca G.
dc.contributor.authorCaggianelli G.
dc.contributor.authorPellerano G.
dc.contributor.authorMollica G.
dc.contributor.authorBugedo G.
dc.contributor.authorWrigge H.
dc.contributor.authorMulier J.P.
dc.contributor.authorVandenbrande J.
dc.contributor.authorGeib J.
dc.contributor.authorYaqub J.
dc.contributor.authorFlorez J.
dc.contributor.authorMayoral J.F.
dc.contributor.authorSprung J.
dc.contributor.authorVan Limmen J.
dc.contributor.authorBos L.D.J.
dc.contributor.authorde Baerdemaeker L.
dc.contributor.authorJamaer L.
dc.contributor.authorSpagnolo L.
dc.contributor.authorStrys L.
dc.contributor.authorGil M.G.
dc.contributor.authorGama de Abreu M.
dc.contributor.authorVidal Melo M.F.
dc.contributor.authorSchultz M.J.
dc.contributor.authorUnzueta M.C.
dc.contributor.authorMoral M.V.
dc.contributor.authorFerner M.
dc.contributor.authorHollmann M.W.
dc.contributor.authorWeiss M.
dc.contributor.authorVanoni M.
dc.contributor.authorSchaefer M.S.
dc.contributor.correspondenceNasa P.
dc.contributor.otherMahidol University
dc.date.accessioned2025-09-22T18:09:11Z
dc.date.available2025-09-22T18:09:11Z
dc.date.issued2025-01-01
dc.description.abstractBackground: 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.
dc.identifier.citationBritish Journal of Anaesthesia (2025)
dc.identifier.doi10.1016/j.bja.2025.07.076
dc.identifier.eissn14716771
dc.identifier.issn00070912
dc.identifier.pmid40930872
dc.identifier.scopus2-s2.0-105015599329
dc.identifier.urihttps://repository.li.mahidol.ac.th/handle/123456789/112115
dc.rights.holderSCOPUS
dc.subjectMedicine
dc.titleAssociation of intraoperative end-tidal CO2 levels with postoperative outcomes: a patient-level analysis of two randomised clinical trials
dc.typeArticle
mu.datasource.scopushttps://www.scopus.com/inward/record.uri?partnerID=HzOxMe3b&scp=105015599329&origin=inward
oaire.citation.titleBritish Journal of Anaesthesia
oairecerif.author.affiliationMonash University
oairecerif.author.affiliationCleveland Clinic Foundation
oairecerif.author.affiliationAmsterdam UMC - University of Amsterdam
oairecerif.author.affiliationMedizinische Universität Wien
oairecerif.author.affiliationHospital Clínic de Barcelona
oairecerif.author.affiliationIRCCS San Martino Polyclinic Hospital
oairecerif.author.affiliationNuffield Department of Medicine
oairecerif.author.affiliationUniversitätsklinikum Carl Gustav Carus Dresden
oairecerif.author.affiliationCentro de Investigación Biomédica en Red de Enfermedades Respiratorias
oairecerif.author.affiliationHospital Israelita Albert Einstein
oairecerif.author.affiliationAntoni van Leeuwenhoek Ziekenhuis
oairecerif.author.affiliationMelbourne Medical School
oairecerif.author.affiliationMahidol Oxford Tropical Medicine Research Unit
oairecerif.author.affiliationNew Cross Hospital
oairecerif.author.affiliationHelicopter Emergency Medical Service Lifeliner 1

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