STUDY TITLE :

To determine the correlation between

ETCO2 and blood lactates in patients pre-
senting to Emergency department with
shock

NAME OF THE INVESTIGATOR :

Dr. Palukurthi Moses Aadarsh

NAME OF THE SUB-INVESTIGATOR/GUIDE :

Dr. Karthik Ravikanti

SITE OF STUDY :
AIG HOSPITAL NO 134 PLOT NO 2/3/4/5 Survey 1
Mind space road, Gachibowli Hyderabad telan-
gana - 500032

INTRODUCTION

Shock is a life-threatening condition of circulatory

failure, causing inadequate oxygen delivery to meet
cellular metabolic needs and oxygen consumption
requirements, producing cellular and tissue hypoxia.
In the emergency department, shock is a common
life threatening condition where in one study of 103
patients with undifferentiated shock presenting to a
busy, urban ED, 36 percent of patients had hypov-
olemic shock, 33 percent had septic shock, 29 per-
cent had cardiogenic shock, and 2 percent had other
forms of shock (1).

Predicting a patients progression to shock is still un-

der study and is an active field of translational re-
search. (2) Traditional therapy of shock followed con-
trolling markers such as blood pressure, central ve-
nous pressure, heart rate rather than focusing on ad-
equate tissue oxygenation and perfusion but this
was proved to be futile since measuring such mark-
ers was useful only during cases of severe hypoten-
sion.(3)

The use of invasive monitoring such as capnography

has been useful in situations requiring CPR preceded
by cardiac arrest and outcome of the patients was
determined by capnography waveforms and ETCO2
values.(4) There is a decrease in the elimination of
CO2 from the lungs due to decreased cardiac output
in a patient suffering with cardiac arrest. Therefore
ETCO2 is used a tool to prognosticate and used as a
marker of futility.(5) ETCO2 has been documented to
decrease in volume related hypotensive states
where the cardiac output is reduced.

In their 2004 and 2008 sepsis guidelines, Dellinger

et al. recommended measurement of lactate on ini-
tial presentation, with an elevated value signifying
tissue hypoperfusion and necessitating aggressive
resuscitation. (6). Notably, serum lactate level >2
mmol/L indicates a condition that is similar to sepsis
with hypotension and there is a significant correla-
tion between mortality rates of patients with an in-
creasing trend of lactates and hypotension.(7)
In this study we would like to determine the correla-
tion between ETCO2 and blood lactates and to com-
pare early mean ETCO2 with outcome of patients in
shock.

REVIEW OF LITERATURE

1. Cheah P. Kheng and Nik H Rahman conducted a

study to determine the use of ETCO2 monitoring in
patients with hypotension in the emergency depart-
ment where a total of 103 patients were studied and
concluded that mean ETCO2 for all patients on ar-
rival was 29.07 ± 9.96 mmHg. Average ETCO2 for pa-
tients in hypovolemic, cardiogenic and septic shock
was 29.64 ± 11.49, 28.60 ± 9.87 and 27.81 ± 7.39
mmHg, respectively. ETCO2 on arrival was positively
correlated with systolic and diastolic BP, MAP, bicar-
bonate, base excess and lactate when analyzed in
all shock patients.

2. Elham Safari and Mehdi Torabi in their research -

Relationship between End-Tidal CO2 (ETCO2) and
Lactate and their Role in Predicting Hospital Mortal-
ity in Critically Ill Trauma Patients; A Cohort Study
noted that in their sample patient population of 250,
using Pearson correlation, an inverse relationship
was noticed between serum lactate and ETCO2, im-
mediately (p<0.0001, r=-0.65).

3. Christopher L Hunter M.D, Salvatore Silvestri, M.D.

Matthew Dean, Jay Falk, M.D., Linda Papa, M.D. from
UCF wrote in their paper End-tidal Carbon Dioxide
Levels are Associated with Mortality in Emergency
Department Patients with Suspected Sepsis that
there was a significant association between levels of
ETCO2 and in-hospital mortality in emergency de-
partment patients with suspected sepsis. There was
a significant inverse relationship
between ETCO2 and lactate levels with a correlation
coefficient of -0.507 (P<0.001), so as lactate levels
increased ETCO2 levels decreased.

4. Syed Shujat Ali; Alexander Dubikaitis; Abdul

Raheem Al Qattan in their paper The Relationship
between End Tidal Carbon Dioxide and Arterial Car-
bon Dioxide during Controlled Hypotensive Anaes-
thesia noted a significant decrease in PaCO (7%)
2

and ETCO (17%) from time 1 to time 2 (p < 0.01)

2

was noted, as was a significant increase in P(a-

ET)CO (48%) and in the Vd /Vt ratio (41.17%) (p <
2 phys

0.01) during the same period.

5. A. Gouel-Che ́ ron1,2,3, L. de Chaisemartin et. Al

in their reseaech paper Low end-tidal CO2 as a real-
time severity marker of intra-anaesthetic acute hy-
persensitivity reactions found that among 86 pa-
tients low etco2 was the only factor which was able
to distinguish mild from severe Acute hypersensitiv-
ity reaction which again consisted of arterial hy-
potension as one of the prominent variables.

3. STUDY OBJECTIVES :

3.A - PRIMARY OBJECTIVE :

To determine the correlation between ETCO2 and
blood lactates in patients presenting to Emergency
department with different types of shock.

3.B - SECONDARY OBJECTIVE :

To assess the association of ETCO2 with total hospi-
tal stay and mortality among patients presenting to
Emergency department with shock.

4. MATERIAL AND METHODS :

STUDY POPULATION :
Study population includes those patients coming to
the emergency department who fits into the inclu-
sion criteria.

DESIGN AND DURATION OF STUDY :

Prospective observational study.

DURATION : 18 months

METHODOLOGY :

DEFINITIONS :
1. Shock - Shock is characterized by decreased oxy-
gen delivery and/or increased oxygen consump-
tion or inadequate oxygen utilization leading to
cellular and tissue hypoxia. It is a life-threatening
condition of circulatory failure and most com-
monly manifested as hypotension (systolic blood
pressure less than 90 mm Hg or MAP less than 65
mmHg).
Shock can be classified into distributive, cardiogenic,
hypovolemic, obstructive and mixed/unknown for eg:
Endocrine causes or cases involving more than 1
type of shock. (8)

Inclusion criteria:
(1) Patient aged 18 years old and above on the day
of presentation
(2) All Patients presenting with shock to the emer-
gency department.

Exclusion criteria:
(1) Patient who arrives to ED in asystole or in a ter-
minal rhythm.
(2) Patient whose blood pressure is unrecordable by
standard non-invasive blood pressure monitoring
on arrival.
(3) Patients who had received resuscitation in the
primary health center prior to transportation to
the study center.
(4) Patients who are end-of-life, terminally ill and
have advanced directives for do not resuscitate
or attempt of active resuscitation.
(5) Elevated [P(a-ETCO2)] gradient of more than 6
mmHg suggesting the presence of a complex
pulmonary pathology that affects the ETCO2
 All patients with shock presenting
to the ED

SUBJECT RECRUITMENT : Study includes patients

presenting to the ED with shock, meeting the inclu-
sion and exclusion criteria to compare and correlate
ETCO2 with blood lactates in patients.

Blood taken for ABG and blood

lactate at time 0hrs

Group patients according to different

types of shock -
Vital signs, ETCO2 and lactate levels mea-
1. Distributive
sured at time '0' and
2. Cardiogenic
subsequently every 30 minutes until 120
3. Hypovolemic
minutes
4. Obstructive
Disposition of patient from the
5. Mixed/unknown ED

Assess ETCO2 with total hospi-

tal stay and mortality
REFERENCES :

1. Kheng CP, Rahman NH. The use of end-tidal carbon

dioxide monitoring in patients with hypotension in the
emergency department. Int J Emerg Med 2012; 5:31.
2. Early Detection of Septic Shock Onset Using Inter-
pretable Machine Learners by Debdipto Misra et. Al J. Clin.
Med. 2021, 10(2), 301.
(https://www.mdpi.com/2077-0383/10/2/301)
3. Wo CC, Shoemaker WC, Appel PL, Bishop MH, Kram
HB, Hardin E: Unreliability of blood pressure and heart rate
to evaluate cardiac output in emergency resuscitation and
critical illness. Crit Care Med 1993,21(2):218–223.
10.1097/00003246-199302000-00012
4. Capnography during cardiopulmonary resuscitation: Cur-
rent evidence and future directions Bhavani Shankar Kodali
and Richard D. Urman J Emerg Trauma Shock. 2014 Oct-
Dec; 7(4): 332–340.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231274/).
5. Sanders AB: Capnometry in emergency medicine. Ann
Emerg Med 1989,18(12):1287–1290. 10.1016/S0196-
0644(89)80260-4.
6. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T,
Cohen J, et al. Surviving sepsis campaign guidelines for
management of severe sepsis and septic shock. Intens
Care Med. 2004;30:536–55.
7. New clinical criteria for septic shock: serum lactate level
as new emerging vital sign Su Mi Lee, Won Suk An doi:
10.21037/jtd.2016.05.55
(https://jtd.amegroups.com/article/view/7772/html)
8. Jean-Louis Vincent, Daniel De Backer Circulatory shock
N Engl J Med. 2013 Oct 31;369(18):1726-34. doi:
10.1056/NEJMra1208943.
(https://www.ncbi.nlm.nih.gov/books/NBK531492/)