Optimizing the intraoperative management of carbon dioxide concentration

This review assesses whether there is a carbon dioxide concentration range that provides optimum benefit to the patient intraoperatively. It includes the physiological effects of carbon dioxide on various organ systems in awake and anesthetized individuals and its clinical effects in the ischemia/reperfusion setting. This review will present views on end-tidal or arterial carbon dioxide tension management in the perioperative period.

Hypocapnia reduces intracranial pressure and is used by clinicians during acute traumatic brain injury, acute intracranial hemorrhage, and acutely growing brain tumors. There is mounting evidence, however, that hypercapnia improves tissue perfusion and oxygenation. Therefore, clinicians may want to induce mild-to-moderate hypercapnia during reperfusion states such as major vascular surgery, organ transplantation, tissue-graft surgery, and cases managed with low mean arterial pressures to control bleeding. As hypercapnia preserves cerebral blood flow even under relatively low perfusion pressures, it may be beneficial during global reperfusion scenarios. This hypothesis needs to be tested extensively before being considered for clinical applications. From a different perspective, current American Heart Association Guidelines recommend 12-15 breaths/min during cardiopulmonary resuscitation and stress the potential negative role of inadvertent hyperventilation on survival outcome. The importance of this concept is discussed briefly.

Overall, the benefits of managing carbon dioxide concentration intraoperatively for the maintenance of cardiac output, tissue oxygenation, perfusion, intracranial pressure, and cerebrovascular reactivity are well defined.