Abstract 13737: Enhanced Prehospital End-Tidal CO2 Monitor Data Analysis for Intubated Severe Traumatic Brain Injury: Striking Findings From the EPIC Study

Background: Studies show that EMS patients are often inadvertently hyperventilated (HV), resulting in hypocapnia. In TBI, HV markedly increases mortality. We evaluated continuous prehospital ETCO2 data in intubated TBI patients. Methods: Analysis of monitor data files (Philips MRx™) from a sample of intubated TBI cases in the EPIC Study (NIH-R01NS071049). Results: Among hundreds of cases, graphical display of continuous ETCO2 from 3 subjects dramatically exemplified commonly-occurring inadvertent HV. Fig 1 shows unrecognized HV lasting nearly 15 min. Fig 2 reveals nearly 14 min of increasing ventilatory rate and progressively worsening hypocapnia. Fig 3 shows nearly 4 min of HV that ends abruptly with clear, sudden recognition and slowing of ventilatory rate that leads to restoration of normal ETCO2 in only a few breaths. The corresponding EMS patient care records (PCR) failed to document the presence, severity, and duration of HV. Conclusions: In a study emphasizing prevention of HV, subsequent evaluation of continuous ETCO2 data revealed many cases of unintentionally rapid manual ventilation and severe hypocapnia, often occurring for long periods. These findings, even in the face of explicit guideline-based training, demonstrate a clear need for routine access to continuous monitor data among intubated patients for quality improvement and in clinical studies. Review of PCRs does not reliably identify mismanagement of ventilation. Furthermore, these findings make it likely that real-time audiovisual feedback technology would improve ventilatory management by alerting providers to unidentified HV that results from the frequent distractions occurring during EMS care.

Essential oils of Cunila galioides and Origanum majorana as anesthetics for Rhamdia quelen: efficacy and effects on ventilation and ionoregulation

ABSTRACT This study evaluated anesthetic efficacy and possible effects of the essential oils (EOs) of Cunila galioides (EOC) and Origanum majorana (EOO) on ventilatory rate (VR) and ionoregulation in Rhamdia quelen. In the anesthesia assessments, 50, 100, 200 and 300 μL L-1 EOC and 50, 100, 200, 300, 400 and 500 μL L-1 EOO were tested, and time for induction to sedation and anesthesia stages, as well as recovery, were taken. A second trial employed lower concentrations of both EOs, 10, 25, 50 and 100 μL L-1, in order to verify VR and Na+, K+ and Cl- whole body net fluxes. Sedation was achieved with both oils at 100 µL L-1, and anesthesia at ≥ 200 µL L-1. There was no significant difference between control and EO-treated groups regarding VR, but all fish subjected to 100 µL L-1 EOC died within 2 h of exposure. Overall, ionic loss declined in the presence of the EOs. The EOC at 200 - 300 μL L-1 and EOO at 400 - 500 μL L-1 present the potential to promote fast anesthesia in R. quelen.

Pulmonary mechanics during rapid mechanical ventilation in rabbits with saline-lavaged lungs

Infants with respiratory failure are frequently mechanically ventilated at rates exceeding 60 breaths/min. We analyzed the effect of ventilatory rates of 30, 60, and 90 breaths/min (inspiratory times of 0.6, 0.3, and 0.2 s, respectively) on the pressure-flow relationships of the lungs of anesthetized paralyzed rabbits after saline lavage. Tidal volume and functional residual capacity were maintained constant. We computed effective inspiratory and expiratory resistance and compliance of the lungs by dividing changes in transpulmonary pressure into resistive and elastic components with a multiple linear regression. We found that mean pulmonary resistance was lower at higher ventilatory rates, while pulmonary compliance was independent of ventilatory rate. The transpulmonary pressure developed by the ventilator during inspiration approximated a linear ramp. Gas flow became constant and the pressure-volume relationship linear during the last portion of inspiration. Even at a ventilatory rate of 90 breaths/min, 28–56% of the tidal volume was delivered with a constant inspiratory flow. Our findings are consistent with the model of Bates et al. (J. Appl. Physiol. 58: 1840–1848, 1985), wherein the distribution of gas flow within the lungs depends predominantly on resistive factors while inspiratory flow is increasing, and on elastic factors while inspiratory flow is constant. This dynamic behavior of the surfactant-depleted lungs suggests that, even with very short inspiratory times, distribution of gas flow within the lungs is in large part determined by elastic factors. Unless the inspiratory time is further shortened, gas flow may be directed to areas of increased resistance, resulting in hyperinflation and barotrauma.