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Observational Study
. 2021 Sep;47(9):961-973.
doi: 10.1007/s00134-021-06470-7. Epub 2021 Jul 24.

Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study

Giuseppe Citerio #  1   2 , Chiara Robba #  3   4 , Paola Rebora  5   6 , Matteo Petrosino  6 , Eleonora Rossi  7 , Letterio Malgeri  8 , Nino Stocchetti  9   10 , Stefania Galimberti #  5   6 , David K Menon #  11 ; Center-TBI participants and investigators
Collaborators, Affiliations
Observational Study

Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study

Giuseppe Citerio et al. Intensive Care Med. 2021 Sep.

Abstract

Purpose: To describe the management of arterial partial pressure of carbon dioxide (PaCO2) in severe traumatic brain-injured (TBI) patients, and the optimal target of PaCO2 in patients with high intracranial pressure (ICP).

Methods: Secondary analysis of CENTER-TBI, a multicentre, prospective, observational, cohort study. The primary aim was to describe current practice in PaCO2 management during the first week of intensive care unit (ICU) after TBI, focusing on the lowest PaCO2 values. We also assessed PaCO2 management in patients with and without ICP monitoring (ICPm), and with and without intracranial hypertension. We evaluated the effect of profound hyperventilation (defined as PaCO2 < 30 mmHg) on long-term outcome.

Results: We included 1100 patients, with a total of 11,791 measurements of PaCO2 (5931 lowest and 5860 highest daily values). The mean (± SD) PaCO2 was 38.9 (± 5.2) mmHg, and the mean minimum PaCO2 was 35.2 (± 5.3) mmHg. Mean daily minimum PaCO2 values were significantly lower in the ICPm group (34.5 vs 36.7 mmHg, p < 0.001). Daily PaCO2 nadir was lower in patients with intracranial hypertension (33.8 vs 35.7 mmHg, p < 0.001). Considerable heterogeneity was observed between centers. Management in a centre using profound hyperventilation (HV) more frequently was not associated with increased 6 months mortality (OR = 1.06, 95% CI = 0.77-1.45, p value = 0.7166), or unfavourable neurological outcome (OR 1.12, 95% CI = 0.90-1.38, p value = 0.3138).

Conclusions: Ventilation is manipulated differently among centers and in response to intracranial dynamics. PaCO2 tends to be lower in patients with ICP monitoring, especially if ICP is increased. Being in a centre which more frequently uses profound hyperventilation does not affect patient outcomes.

Trial registration: ClinicalTrials.gov NCT02210221.

Keywords: Carbon dioxide; Hyperventilation; Intracranial pressure; Outcome; Traumatic brain injury.

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Conflict of interest statement

GC reports grants, personal fees as Speakers’ Bureau Member and Advisory Board Member from Integra and Neuroptics. DKM reports grants from the European Union and UK National Institute for Health Research, during the conduct of the study; grants, personal fees, and non-financial support from GlaxoSmithKline; personal fees from Neurotrauma Sciences, Lantmaanen AB, Pressura, and Pfizer, outside of the submitted work. The other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
(a) Distributions of the daily lowest PaCO2 recorded in the first 7 days of ICU in each participating centre (coloured by country) and overall (grey area). These distributions were estimated by a Gaussian kernel density. (b) Centre-specific mean values (coloured by country) of daily lowest PaCO2 with the corresponding 95% confidence intervals. The solid vertical line represents the overall mean of daily lowest PaCO2 values, and the size of the dots is proportional to the number of patients in the centre. PaCO2 the partial pressure of carbon dioxide, AT Austria, BE Belgium, DE Germany, ES Spain, FI Finland, FR France, HU Hungary, IT Italy, LT Lithuania, NL Netherlands, NO Norway, SE Serbia, UK United Kingdom
Fig. 2
Fig. 2
(a): Scatterplot of the mean daily lowest PaCO2 values in no-ICPm vs ICPm patients in each participating centre (coloured by country). The dashed line represents the line of identity, and a data point on or close to the line indicates that PaCO2 targets in that centre were not affected by the presence of ICP monitoring. The gradient of grey zones on either side of the grey area indicates increasing deviations from this line of identity between values in no-ICPm vs ICPm patients. Each gradation in shade representing one unit change (mmHg). The size of the dots is proportional to the number of ICPm patients at a centre. The outlier centre from Hungary included only two no-ICPm patients, out of a total of 12 patients, with only two measurements each before ending ventilation. (b) Mean of the daily lowest PaCO2 values in ICPm patients with no episodes of elevated ICP (ICP ≤ 20 mmHg) vs ICPm patients with at least one episode of elevated ICP (> 20 mmHg) in each participating centre (coloured by country). The dashed line represents the line of identity, and the size of the dot is proportional to the number of ICPm patients with elevated ICP. PaCO2 the partial pressure of carbon dioxide, AT Austria, BE Belgium, DE Germany, ES Spain, FI Finland, FR France, HU Hungary, IT Italy, LT Lithuania, NL Netherlands, NO Norway, SE Serbia, UK United Kingdom
Fig. 3
Fig. 3
Caterpillar plot of between-centre variation in using profound HV. The figure shows the predicted random intercepts for each centre, on the log-odds scale, along with their 95% prediction intervals. Higher values indicate a higher propensity to use profound HV. A longitudinal random effect logistic model was used to correct for random variation and adjusted for the core IMPACT covariates and elevated ICP. The MOR summarises the between-centre variation: a MOR = 1 indicates no variation, while the larger the MOR is, the larger the variation present. The median odds ratio (MOR = 2.04) refers to the odds of using profound HV between two randomly selected centres for patients with the same covariates and (comparable) random effects
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