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Post-ROSC Ventilation: PaCO2 Goals

Question Type:
Intervention
Full Question:
Among infants and children with ROSC after cardiac arrest in any setting (P), does does ventilation to a specific PaCO2 target (I), compared with compared with ventilation to no specific PaCO2 target (C), change survival with favorable neurologic outcome, survival to 180 days with good neurological outcome, survival to 30 days with good neurological outcome, the likelihood of a good Quality of Life (QoL) after discharge from the hospital, survival to hospital discharge, survival to hospital discharge, survival to 30 days, survival to 60 days, survival to 6 months, survival to ICU discharge (O)?
Consensus on Science:
There are no studies specifically comparing ventilation to a predetermined PaCO2 target in children after cardiac arrest. Furthermore, there are no studies in the prehospital setting. Part A: Hypercapnia Versus Normocapnia For the critical outcome of survival to hospital discharge with favorable/functional neurologic outcome (assessed with PCPC 1–2 or no change with baseline before cardiac arrest), we identified very-low-quality evidence from 1 pediatric observational study of IHCA and OHCA (downgraded for indirectness, imprecision, and serious risk of bias(Bennett 2013, 1534-1542)) involving 195 survivors to at least 6 hours after arrest that there was no association between hypercapnia (PaCO2 greater than 50 mm Hg) and outcome (RR, 0.76; 95% CI, 0.50–1.16). For the important outcome of survival to hospital discharge, we identified very-low-quality evidence from 1 pediatric observational study of IHCA (downgraded for inconsistency, indirectness, imprecision, and serious risk of bias(Del Castillo 2012, 1456-1461)) involving 223 subjects showing that worse outcomes were associated with hypercapnia (PaCO2 50 mm Hg or greater) than when the PaCO2 was less than 50 mm Hg (RR, 0.48; 95% CI, 0.27–0.86). Part B: Hypocapnia Versus Normocapnia For the critical outcome of survival to hospital discharge with favorable/functional neurologic outcome (assessed with PCPC 1–2 or no change with baseline before cardiac arrest), we identified very-low-quality evidence from 1 pediatric observational study of IHCA and OHCA (downgraded for indirectness, imprecision, and serious risk of bias(Bennett 2013, 1534-1542)), involving 195 survivors to at least 6 hours postarrest, that failed to show an association between hypocapnia (PaCO2 less than 30 mm Hg) and outcome (RR, 0.70; 95% CI, 0.43–1.14). For the important outcome of survival to hospital discharge, we identified very-low-quality evidence from 1 pediatric observational study of IHCA (downgraded for inconsistency, indirectness, imprecision and serious risk of bias(Del Castillo 2012, 1456-1461)), involving 223 subjects, that failed to show an association between hypocapnia (PaCO2 less than 30 mm Hg) and outcome (RR, 0.83; 95% CI, 0.46–1.51).
Treatment Recommendation:
We suggest that rescuers measure PaCO2 after ROSC and target a value appropriate to the specific patient condition, although the confidence in effect estimates is so low that the panel decided a recommendation for a specific PaCO2 target was too speculative.
CoSTR Attachments:
Final CoSTR ventilation target in children recovering from cardiac arrest_January 19, 2015.docx    
Final Recommendations January 19 2015.docx    
PEDS 815 Agreement and Disagreement.xlsx    
Risk of Bias(1).pdf    

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