An audit of a change in carbon dioxide level targeting in patients admitted to the intensive care unit: A before-and-after practice change audit

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Many patients admitted to the intensive care unit (ICU) for on-going clinical management receive mechanical ventilation. Mechanical ventilation is the process by which a patient’s breathing is supported by a machine (ventilator). While receiving mechanical ventilation the patient’s intensive care clinicians make clinical decisions about their patient’s breathing. Beginning in the second half of 2016, and based on emerging evidence, the ICU Consultant group has agreed to implement a practice change in their management of carbon dioxide levels in mechanically ventilated patients. This practice change is termed ‘permissive mild hypercapnia’ and involves clinicians’ targeting of arterial carbon dioxide tension values of 50-55 mmHg instead of the usual value of 35-45 mmHg. This change applies to all adult mechanically ventilated patients, except for those who required extracorporeal membrane oxygen (ECMO) therapy, those in whom death is deemed imminent and those in whom a higher CO2 level is contraindicated for other clinical reasons. We plan to systematically audit biochemical, physiological and patient-centred outcomes and compare such outcomes after the introduction of this practice change with outcomes in patients before the practice change. Importantly, the knowledge generated by this audit may inform future interventional studies aimed at further optimising disease-specific PaCO2strategies for the care of critically ill patients. This audit will take a similar path to the recent conservative oxygen therapy trial, where a practice change allowed slightly lower than usual oxygen levels to be targeted at Austin Hospital and a before and after audit was conducted and showed clear benefits in patient outcomes including an increase in earlier spontaneous ventilation.

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