Invasive CO2 monitoring with arterial line compared to end tidal CO2 during peroral endoscopic myotomy

Rodrigo Duarte-Chavez; Amy Tyberg; Avik Sarkar; Haroon M. Shahid; Bhargav Vemulapalli; Sardar Shah-Khan; Monica Gaidhane; Michel Kahaleh

doi:10.1055/a-2048-1312

Endoscopy International Open, Table of Contents

CC BY-NC-ND 4.0 · Endosc Int Open 2023; 11(05): E468-E473
DOI: 10.1055/a-2048-1312

Original article

Invasive CO₂ monitoring with arterial line compared to end tidal CO₂ during peroral endoscopic myotomy^[*]

Authors

Rodrigo Duarte-Chavez

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Amy Tyberg

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Avik Sarkar

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Haroon M. Shahid

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Bhargav Vemulapalli

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Sardar Shah-Khan

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Monica Gaidhane

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States
Michel Kahaleh

¹Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, United States

Abstract

Background and study aims Peroral endoscopic myotomy (POEM) has become a recognized treatment for achalasia. The technique requires CO₂ insufflation. It is estimated that the partial pressure of CO₂ (PaCO₂) is 2 to 5 mm Hg higher than the end tidal CO₂ (etCO₂), and etCO₂ is used as a surrogate for PaCO₂ because PaCO₂ requires an arterial line. However, no study has compared invasive and noninvasive CO₂ monitoring during POEM.

Patients and methods Seventy-one patients who underwent POEM were included in a prospective comparative study. PaCO₂ plus etCO₂ was measured in 32 patients (invasive group) and etCO₂ only in 39 matched patients (noninvasive group). Pearson correlation coefficient (PCC) and Spearman’s Rho were used to calculate the correlation between PaCO₂ and ETCO₂.

Results PaCO₂ and ETCO₂ were strongly correlated: PCC R value: 0.8787 P ≤ 0.00001, Spearman’s Rho R value: 0.8775, P ≤ 0.00001. Within the invasive group, the average difference between PaCO₂ and ETCO₂ was 3.39 mm Hg (median 3, standard deviation 3.5), within the 2- to 5-mm Hg range. The average procedure time (scope in to scope out) was increased 17.7 minutes (P = 0.044) and anesthesia duration was 46.3 minutes. Adverse events (AEs) included three hematomas and one nerve injury in the invasive group and one pneumothorax in the noninvasive group. There were no differences in AE rates between the groups (13 % vs 3 % P = 0.24).

Conclusions Universal PaCO₂ monitoring contributes to increased procedure and anesthesia times without any decrease in AEs in patients undergoing POEM. CO₂ monitoring with an arterial line should only be performed in patients with major cardiovascular comorbidities; in all other patients, ETCO₂ is an appropriate tool.

Full Text

References

References
1 Inoue H, Shiwaku H, Iwakiri K. et al. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 2018; 30: 563-579
2 Zaninotto G, Bennett C, Boeckxstaens G. et al. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31
3 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
4 Weusten B, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 498-515
5 Bapaye A, Korrapati SK, Dharamsi S. et al. Third space endoscopy: lessons learnt from a decade of submucosal endoscopy. J Clin Gastroenterol 2020; 54: 114-129
6 Yamashita-Ichimura M, Toyama E, Sasoh M. et al. Bladder pressure monitoring and CO2 gas-related adverse events during per-oral endoscopic myotomy. J Clin Monit Comput 2018; 32: 1111-1116
7 Rackley CR. Monitoring during mechanical ventilation. Respir Care 2020; 65: 832-846
8 Ortega R, Connor C, Kim S. et al. Monitoring ventilation with capnography. N Engl J Med 2012; 367: e27
9 Sbaraglia F, Familiari P, Maiellare F. et al. Pediatric anesthesia and achalasia: 10 years’ experience in peroral endoscopy myotomy management. J Anesth Analg Crit Care 2022;
10 Tanaka E, Murata H, Minami H. et al. Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series. J Anesth 2014; 28: 456-459
11 Williams CB. Who's for CO2?. Gastrointest Endosc 1986; 32: 365-367
12 Bretthauer M, Kalager M, Adami HO. et al. Who is for CO2? Slow adoption of carbon dioxide insufflation in colonoscopy. Ann Intern Med 2016; 165: 145-146
13 Darisetty S, Nabi Z, Ramchandani M. et al. Anesthesia in per-oral endoscopic myotomy: A large tertiary care centre experience. Indian J Gastroenterol 2017; 36: 305-312
14 Akintoye E, Kumar N, Obaitan I. et al. Peroral endoscopic myotomy: a meta-analysis. Endoscopy 2016; 48: 1059-1068
15 Ren Z, Zhong Y, Zhou P. et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267-3272
16 Jayan N, Jacob JS, Mathew M. et al. Anesthesia for peroral endoscopic myotomy: A retrospective case series. J Anaesthesiol Clin Pharmacol 2016; 32: 379-381
17 Talukdar R, Inoue H, Nageshwar Reddy D. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc 2015; 29: 3030-3046
18 Cai MY, Zhou PH, Yao LQ. et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014; 80: 1046-1055
19 Zhang XC, Li QL, Xu MD. et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy 2016; 48: 967-978
20 Bang YS, Park C. Anesthetic consideration for peroral endoscopic myotomy. Clin Endosc 2019; 52: 549-555
21 Yang D, Pannu D, Zhang Q. et al. Evaluation of anesthesia management, feasibility and efficacy of peroral endoscopic myotomy (POEM) for achalasia performed in the endoscopy unit. Endosc Int Open 2015; 3: E289-E295
22 Razi E, Moosavi GA, Omidi K. et al. Correlation of end-tidal carbon dioxide with arterial carbon dioxide in mechanically ventilated patients. Arch Trauma Res 2012; 1: 58-62
23 Sullivan KJ, Kissoon N, Goodwin SR. End-tidal carbon dioxide monitoring in pediatric emergencies. Pediatr Emerg Care 2005; 21: 327-332 quiz 333–325
24 Loser B, Werner YB, Punke MA. et al. Anesthetic considerations for patients with esophageal achalasia undergoing peroral endoscopic myotomy: a retrospective case series review. Can J Anaesth 2017; 64: 480-488
25 Fujimoto S, Suzuki M, Sakamoto K. et al. Comparison of End-Tidal, Arterial, Venous, and Transcutaneous PCO2. Respir Care 2019; 64: 1208-1214
26 Gaur P, Harde M, Gujjar P. et al. A study of partial pressure of arterial carbon dioxide and end-tidal carbon dioxide correlation in intraoperative and postoperative period in neurosurgical patients. Asian J Neurosurg 2017; 12: 475-482
27 Yamanaka MK, Sue DY. Comparison of arterial-end-tidal PCO2 difference and dead space/tidal volume ratio in respiratory failure. Chest 1987; 92: 832-835
28 Fletcher R. The arterial-end-tidal CO2 difference during cardiothoracic surgery. J Cardiothorac Anesth 1990; 4: 105-117
29 Burrows FA. Physiologic dead space, venous admixture, and the arterial to end-tidal carbon dioxide difference in infants and children undergoing cardiac surgery. Anesthesiology 1989; 70: 219-225

Invasive CO2 monitoring with arterial line compared to end tidal CO2 during peroral endoscopic myotomy[*]

Authors

Invasive CO₂ monitoring with arterial line compared to end tidal CO₂ during peroral endoscopic myotomy^[*]