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Volume 3 Supplement 1

ESICM LIVES 2015

In neuro critical care, capnia can be optimally controlled using a closed-loop ventilation system based on end-tidal CO2 signal (intellivent-asv®): preliminary results of a prospective interventional study

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Introduction

Both hypo- and hypercapnia can be deleterious to brain injured patients. Due to the variability of CO2 production and elimination and to the unpredictable effects of ventilator settings changes, strict arterial CO2 partial pressure (PaCO2) control is difficult to obtain. Conceivably, using expired (end-tidal) CO2 as the input signal of closed-loop ventilation (Intellivent-ASV®) should optimize CO2 control compared to manual ventilator setting changes based on PaCO2 measurements.

Objectives

The aim of this study was to compare PaCO2 evolution over time during standard controlled ventilation and during Intellivent-ASV®.

Methods

Prospective interventional randomized study with a crossover design. Comparison of PaCO2 evolution during two sequential 2-hour periods of ventilation (standard ventilation and Intellivent-ASV® version VUP02.11c in the “brain injury setting”), applied in random-order. A one-hour washout period was inserted between both periods. Arterial blood gas analysis was performed every 30 minutes. The number of manual settings adjustments made on the ventilator and actions performed to reduce intracranial pressure (ICP) were also recorded. Due to the small number of patients in this preliminary dataset, no statistical differences were tested.

Results

(medians [IQR]):11 patients were included (6 severe traumatic brain injury, 4 subarachnoid hemorrhage and 1 intra-cerebral hematoma). Age: 52 [42-54] years. Body mass index: 25.5 [24.7-27.0] kg/m2, GCS at admission: 6 [4-6.5]. SAPS 2 score: 42 [32-50]. PaCO2 was 36 [33-37] mmHg (range: 28 and 43 mmHg) during standard ventilation and 36 [34-37] (range: 30 and 43 mmHg) during Intellivent-ASV®. DeltaPaCO2 between two consecutive PaCO2 measurements are illustrated in Figure 1.

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Figure 1

During standard ventilation, 22 settings adaptations were performed whereas only two manual adjustments were made during Intellivent-ASV®. Four (2 increase in sedation and 2 hypertonic saline administration) and 2 (increase in sedation) actions were performed in order to decrease ICP during standard ventilation and Intellivent-ASV® respectively.

Conclusions

The Intellivent-ASV® CO2-regulated closed-loop ventilation mode can be safely used to deliver automated ventilation in brain injured patients. PaCO2 never reached extreme values and delta PaCO2 were very low during Intellivent-ASV®. Accordingly, fewer ventilator settings adaptations were required during Intellivent-ASV®. These preliminary results are promising and more patients must be included to evaluate the potential advantage of using Intellivent-ASV® to optimize the control of capnia during neuro-resuscitation.

Author information

Correspondence to L Piquilloud.

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Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0), which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Keywords

  • Traumatic Brain Injury
  • Hypertonic Saline
  • Severe Traumatic Brain Injury
  • Ventilator Setting
  • Brain Injured Patient