Department of Anesthesiology
Oulu University Hospital
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
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: email@example.com.
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