End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study

Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO(2) as a proxy for PaCO(2). We assessed whether the difference between end tidal CO(2) and PaCO(2) at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO(2) gap—defined as the difference between end tidal CO(2) and PaCO(2)—and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO(2) gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO(2) and PaCO(2) at admission was low (Pearson's r = .287). The mean CO(2) gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO(2) gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO(2) gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO(2) and PaCO(2) is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO(2) was significantly lower than PaCO(2), making it an unreliable proxy for PaCO(2) when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.