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Communications to the Editor |

Continuous Gastric Mucosal Capnometry Is Affected by Enteral Nutrition : Potential for Misinterpretation of Tissue Oxygenation FREE TO VIEW

Tero I. Ala-Kokko, MD, PhD, EDIC; Jouko Laurila, MD
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Department of Anesthesiology Oulu University Hospital Oulu, Finland



Chest. 1999;115(5):1482-1483. doi:10.1378/chest.115.5.1482-a
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To the Editor:

The editorial by Fink (September 1998)1provided excellent guidelines on the use of tissue capnometry in critical care. In addition to the mechanisms by which carbon dioxide can enter the intestinal lumen that are listed in his editorial, it has been shown that carbon dioxide can be formed during enteral feeding.2

As an example of this frequent problem in clinical practice, we describe a patient in whom mucosal hypercapnia was induced by enteral feeding. This case is a 68-year-old man who underwent elective correction of an infrarenal abdominal aortic aneurysm. He subsequently developed septic shock and acute renal failure. Continuous intragastric capnometry (Tonocap; Datex-Ohmeda; Helsinki, Finland) was begun due to suspected gut hypoperfusion. Severe mucosal hypercapnia and an increase in the gap between end-tidal carbon dioxide and mucosal carbon dioxide was observed (Fig 1). This was associated with the administration of standard enteral feeding formula (Pre-Nutrison; N.V. Nutricia; Zoetermeer, Holland). During the period described, enteral nutrition was first infused at a rate of 25 mL/h, followed later with a higher rate of 38 mL/h (Fig 1). Furthermore, lactactemia and systemic acidosis were absent during the periods of mucosal hypercapnia. Discontinuation of enteral feeding led to normalization of the mucosal carbon dioxide level.

We agree with Dr. Fink that intraluminal capnometry has an important role in cases where oxygen delivery in the microvasculature is the problem. The new technique of continuous monitoring of intraluminal carbon dioxide should be very advantageous in these unstable patients under resuscitation. Continuous monitoring allows an easy and rapid method for observing the patient’s response to therapeutic interventions by detecting short-term changes in mucosal carbon dioxide level.3This type of real-time measurement is not possible using intermittent measurements; this is especially true in the case of capnometry, which is relatively time consuming to perform. Following the initial stabilization, however, early enteral feeding is recommended in critically ill patients.4 In these patients already on enteral feeding, the monitoring of the intragastric carbon dioxide level will have a limited role in the detection of gut dysoxia.

Correspondence to: Tero I. Ala-Kokko, MD, PhD, EDIC, Department of Anesthesiology, Oulu University Hospital, PO Box 22, FIN-90220 Oulu, Finland; e-mail: tak@cc.oulu.fi.

Figure Jump LinkFigure 1. Tissue oxygenation parameters reproduced from patient data management system (Clinisoft CIMS; Datex-Ohmeda; Helsinki, Finland).Grahic Jump Location
Fink, MP (1998) Tissue capnometry as a monitoring strategy for critically ill patients: just about ready for prime time.Chest114,667-670. [CrossRef]
 
Marik, PE, Lorenzana, A Effect of tube feedings on the measurement of gastric intramucosal pH.Crit Care Med1996;24,1498-1500. [CrossRef]
 
Knichwitz, G, Van Aken, H, Brussel, T Gastrointestinal monitoring using measurement of intramucosal PCO2.Anesth Analg1998;87,134-142
 
Krueger, KJ, DiPalma, JA The optimal diet for the critically ill patient.Curr Opin Crit Care1997;3,127-131. [CrossRef]
 

Figures

Figure Jump LinkFigure 1. Tissue oxygenation parameters reproduced from patient data management system (Clinisoft CIMS; Datex-Ohmeda; Helsinki, Finland).Grahic Jump Location

Tables

References

Fink, MP (1998) Tissue capnometry as a monitoring strategy for critically ill patients: just about ready for prime time.Chest114,667-670. [CrossRef]
 
Marik, PE, Lorenzana, A Effect of tube feedings on the measurement of gastric intramucosal pH.Crit Care Med1996;24,1498-1500. [CrossRef]
 
Knichwitz, G, Van Aken, H, Brussel, T Gastrointestinal monitoring using measurement of intramucosal PCO2.Anesth Analg1998;87,134-142
 
Krueger, KJ, DiPalma, JA The optimal diet for the critically ill patient.Curr Opin Crit Care1997;3,127-131. [CrossRef]
 
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