Assessing the cost-effectiveness of capnography for end-tidal CO2 monitoring during in-hospital cardiac arrest: A middle-income country perspective analysis.

Study objective: To evaluate the cost-effectiveness of EtCO2 monitoring during in-hospital cardiorespiratory arrest (CA) care outside the intensive care unit (ICU) and emergency room department. Design: We performed a cost-effectiveness analysis based on a simple decision model cost analysis and reported the study using the CHEERS checklist. Model inputs were derived from a retrospective Brazilian cohort study, complemented by information obtained through a literature review. Cost inputs were gathered from both literature sources and contacts with hospital suppliers. Setting: The analysis was carried out from the perspective of a tertiary referral hospital in a middle-income country. Participants: The study population comprised individuals experiencing in-hospital CA who received cardiopulmonary resuscitation (CPR) by rapid response team (RRT) in a hospital ward, not in the ICU or emergency room department. Interventions: Two strategies were assumed for comparison: one with an RRT delivering care without capnography during CPR and the other guiding CPR according to the EtCO2 waveform. Main outcome measures: Incremental cost-effectiveness rate (ICER) to return of spontaneous circulation (ROSC), hospital discharge, and hospital discharge with good neurological outcomes. Results: The ICER for EtCO2 monitoring during CPR, resulting in an absolute increase of one more case with ROSC, hospital discharge, and hospital discharge with good neurological outcome, was calculated at Int$ 515.78 (361.57-1201.12), Int$ 165.74 (119.29-248.4), and Int$ 240.55, respectively. Conclusion: In managing in-hospital CA in the hospital ward, incorporating EtCO2 monitoring is likely a cost-effective measure within the context of a middle-income country hospital with an RRT.

End-tidal carbon dioxide measurements as a surrogate to arterial carbon dioxide during pediatric laparoscopic surgeries: a prospective observational cohort study.

BACKGROUND: Maintaining normocapnia during mechanical ventilation in anesthetized children during laparoscopic surgeries is highly recommended. There is a debate regarding the use of capnography (ETCO2) as a trend monitor for evaluation of arterial carbon dioxide levels (PaCO2). We analyzed the relationship between ETCO2 and PaCO2 with time in elective pediatric laparoscopic surgeries. METHODS: This study was a prospective observational cohort analysis of 116 paired comparisons between PaCO2 and ETCO2 computed from 29 children (ASA I, 12-72 months). Arterial blood samples were withdrawn before, at 15 minutes and 30 minutes during pneumoperitoneum and 1 minute after deflation. ETCO2 value was recorded simultaneously, while arterial blood was withdrawn. PaCO2-ETCO2 relationship was evaluated by Pearson's correlation coefficients and Bland Altman Method of agreement. RESULTS: Out of the 116 comparisons analyzed, a PaCO2-ETCO2 difference beyond 0 to ≤ 5 mmHg was recorded in 71 comparisons (61.2%) with negative difference in 34 comparisons (29.3%). A positive significant correlation between PaCO2 and ETCO2 was recorded before (r = 0.617, p = 0.000) and at 15 minutes (r = 0.582, p = 0.001), with no significant correlation at 30 minutes (r = 0.142, p = 0.461), either after deflation (r = 0.108, p = 0.577). Bland-Altman plots showed agreement between ETCO2 and PaCO2 before inflation with mean PaCO2-ETCO2 difference 0.14 ± 5.6 mmHg (limits of 95% agreement -10.84-11.2, simple linear regression testing p-value 0.971), with no agreement at 15 minutes (0.51 ± 7.15, -13.5-14.5, p = 0.000), 30 minutes. (2.62 ± 7.83, -12.73-17.97, p = 0.000), or after deflation (1.81 ± 6.56, -10.93-14.55, p = 0.015). CONCLUSION: Usage of capnography as a trend monitor in pediatric laparoscopic surgeries may not be a reliable surrogate for PaCO2 levels. TRIAL REGISTRATION: Clinical Trials. gov (Identifier: NCT03361657).

Data supporting the use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review.

The data presented in this article are related to the research article, "The Use of End-Tidal Carbon Dioxide (ETCO2) Measurement to Guide Management of Cardiac Arrest: A Systematic Review" [1]. This article is a systematic review and meta-analysis of existing data on the subject of whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adult patients experiencing cardiac arrest in any setting. These data are made publicly available to enable critical or extended analyses.

The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review.

AIMS: To identify whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adults experiencing cardiac arrest in any setting. METHODS: Systematic review. We included randomized controlled trials, cohort studies, and case-control studies of adult cardiac arrest in any setting that reported specific (rather than pooled) ETCO2 values and attempted to correlate those values with prognosis. Full-text articles were searched on EmBASE, MEDLINE, and Cochrane Database. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) guidelines were followed, assigning levels of quality to all evidence used in the meta-analysis. RESULTS: Seventeen observational studies, describing a total of 6198 patients, were included in the qualitative synthesis, and five studies were included in the meta-analysis. The available studies provided consistent but low-quality evidence that ETCO2 measurements ≥10mmHg, obtained at various time points during CPR, are substantially related to ROSC. Additional cut-off values were also found. Initial ETCO2 or 20-min ETCO2>20mmHg appears to be a better predictor of ROSC than the 10mmHg cut off value. A ETCO2<10mmHg after 20min of CPR is associated with a 0.5% likelihood of ROSC. CONCLUSIONS: Based upon existing evidence, ETCO2 levels do seem to provide limited prognostic information for patients who have experienced cardiac arrest. Given the many potential confounders that can influence initial ETCO2 levels, extreme or trending values may be more useful than static mid-range levels. Additional well-designed studies are needed to define optimal timing for the measurement of ETCO2 for prognostic purposes.

Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support.

BACKGROUND: End-tidal carbon dioxide (ETCO2) correlates with systemic blood flow and resuscitation rate during cardiopulmonary resuscitation (CPR) and may potentially direct chest compression performance. We compared ETCO2-directed chest compressions with chest compressions optimized to pediatric basic life support guidelines in an infant swine model to determine the effect on rate of return of spontaneous circulation (ROSC). METHODS AND RESULTS: Forty 2-kg piglets underwent general anesthesia, tracheostomy, placement of vascular catheters, ventricular fibrillation, and 90 seconds of no-flow before receiving 10 or 12 minutes of pediatric basic life support. In the optimized group, chest compressions were optimized by marker, video, and verbal feedback to obtain American Heart Association-recommended depth and rate. In the ETCO2-directed group, compression depth, rate, and hand position were modified to obtain a maximal ETCO2 without video or verbal feedback. After the interval of pediatric basic life support, external defibrillation and intravenous epinephrine were administered for another 10 minutes of CPR or until ROSC. Mean ETCO2 at 10 minutes of CPR was 22.7±7.8 mm Hg in the optimized group (n=20) and 28.5±7.0 mm Hg in the ETCO2-directed group (n=20; P=0.02). Despite higher ETCO2 and mean arterial pressure in the latter group, ROSC rates were similar: 13 of 20 (65%; optimized) and 14 of 20 (70%; ETCO2 directed). The best predictor of ROSC was systemic perfusion pressure. Defibrillation attempts, epinephrine doses required, and CPR-related injuries were similar between groups. CONCLUSIONS: The use of ETCO2-directed chest compressions is a novel guided approach to resuscitation that can be as effective as standard CPR optimized with marker, video, and verbal feedback.