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ETCO2 to Predict Outcome of Cardiac Arrest

Question Type:
Prognostic
Full Question:
Among adults who are in cardiac arrest in any setting  (P), does does any ETCO2 level value, when present  (I), compared with compared with any ETCO2 level below that value  (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?
Consensus on Science:
We did not identify any evidence to address the critical outcome of neurologically intact survival.For the critical outcome of survival at discharge, we have identified low-quality evidence (downgraded for serious risk of bias and serious imprecision) from 1 observational study enrolling 127 patients(Ahrens 2001, 391) showing a correlation with initial ETCO2 10 mm Hg (1.33 kPa) or greater when compared with less than 10 mm Hg (OR, 11.4; 95% CI, 1.4–90.2).For the critical outcome of survival at discharge, we have identified low-quality evidence (downgraded for serious risk of bias and serious imprecision) from 1 observational study enrolling 127 patients(Ahrens 2001, 391) showing a correlation with 20 minutes of ETCO2 20 mm Hg (2.67 kPa or greater when compared with less than 20 mm Hg (OR, 20.0; 95% CI, 2.0–203.3).For the important outcome of ROSC, we have identified moderate-quality evidence (downgraded for serious risk of bias) from 3 observational studies enrolling 302 patients(Callaham 1990, 358; Cantineau 1996, 791; Ahrens 2001, 391) showing a correlation with initial ETCO2 10 mm Hg or greater when compared with less than 10 mm Hg (OR, 10.7; 95% CI, 5.6–20.3).For the important outcome of ROSC, we have identified very-low-quality evidence (downgraded for very serious risk of bias, serious inconsistency, and serious imprecision) from 3 observational studies enrolling 367 patients(Wayne 1995, 762; Levine 1997, 301; Ahrens 2001, 391) showing correlation with 20 minutes ETCO2 10 mm Hg or greater when compared with less than 10 mm Hg (OR, 181.6; 95% CI, 40.1–822.6).
Treatment Recommendation:
We recommend against using ETCO2 cutoff values alone as a mortality predictor or on the decision to stop a resuscitation attempt (strong recommendation, low-quality evidence).We suggest that an ETCO2 10 mm Hg or greater measured after tracheal intubation or after 20 minutes of resuscitation, may be a predictor of ROSC (weak recommendation, low-quality evidence).We suggest that an ETCO2 10 mm Hg or greater measured after tracheal intubation, or an ETCO2 20 mm Hg or greater measured after 20 minutes of resuscitation may be a predictor of survival to discharge (weak recommendation, moderate-quality evidence).Values, Preferences, and Task Force InsightsIn making the strong recommendations against using a specific ETCO2 cutoff value alone as a mortality predictor or on the decision to stop a resuscitation attempt, we have put a higher value on not relying on a single variable (ETCO2) and cutoff value when their usefulness in actual clinical practice, and variability according to the underlying cause of cardiac arrest, has not been established and there are considerable knowledge gaps. The task force was concerned that the etiology (eg, asphyxia, PE) of cardiac arrest could affect ETCO2 values, and that there was a risk of self-fulfilling prophecy if specific threshold values were followed. There was concern about the accuracy of ETCO2 values measured during CPR. During open discussions there were requests that the ILCOR recommendation be far more prescriptive to prevent futile and prolonged resuscitation attempts.
CoSTR Attachments:
CoS and TR ETCO2_n.docx    
SOF Table ETCO2_n.docx    

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