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Postresuscitation Ventilation Strategy

Question Type:
Intervention
Full Question:
Among adults with ROSC after cardiac arrest in any setting  (P), does does ventilation to a specific PaCO2 goal  (I), compared with compared with no specific strategy or a different PaCO2 goal  (C), change Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year (O)?
Consensus on Science:
No studies have specifically randomized patients to ventilation to a specific PaCO2 goal.Hypocapnia For the critical outcome of neurologically favorable survival, 2 very-low-quality cohort studies(Roberts 2013, 2107; Lee 2014, 55) with a total of 8376 patients (downgraded for very serious concerns about risk of bias and imprecision) showed hypocapnia (less than 3.0 kPa and less than 4.7 kPa, respectively) was associated with a worse outcome. For the critical outcome of death (or failure to be discharged home), 1 very-low-quality cohort study(Schneider 2013, 927) of 6881 patients (downgraded for very serious concerns about risk of bias and imprecision) showed hypocapnia (less than 4.7 kPa) was associated with a worse outcome.Hypercapnia For the critical outcome of neurologically favorable survival, 3 observational cohort studies showed inconsistent associations between hypercapnia and outcome (very-low-quality evidence, downgraded for very serious concerns about risk of bias, imprecision, and inconsistency). One study(Roberts 2013, 2107) with a total of 123 patients showed worse outcome in patients ventilated to hypercapnia (PaCO2 greater than 6.7 kPa). One study(Lee 2014, 55) with a total of 850 patients showed no difference in outcome for patients ventilated to hypercapnia (PaCO2 greater than 6.0 kPa). One study(Vaahersalo 2014, 1463) with a total of 409 patients showed better outcome for patients ventilated to hypercapnia (PaCO2 5.1–10.1 kPa).For the critical outcome of death (or failure to be discharged home), 2 cohort studies showed uncertain associations with outcome (downgraded for very serious concerns about risk of bias and imprecision). One study(Schneider 2013, 927) with a total of 16 542 patients, showed no difference in outcome for patients ventilated to hypercapnia (PaCO2 greater than 6.0 kPa). One study(Lee 2014, 55) with a total of 850 patients showed a higher mean PaCO2 in survivors.
Treatment Recommendation:
We suggest maintaining PaCO2 within a normal physiological range as part of a post-ROSC bundle of care (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force InsightsIn making this recommendation, the task force did not find good evidence to suggest or recommend either hypercarbia or hypocarbia. In the absence of evidence to that end, combined with a potential suggestion of harm, we suggest maintaining normocarbia. Many physiological considerations may influence selection of PaCO2 goals for individual patients.
CoSTR Attachments:
ALS 571 Ventilation to a specific pCO2 or pO2 goal_n.docx    
ILCOR ALS571-post review Final.pdf    

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