Ventilatory targets after cardiac arrest

The mortality of postcardiac arrest patients has gradually reduced in years but it still is as high as 50%, despite advancements in the diagnostic and therapeutic approaches, i.e. revascularization and therapeutic moderate hypothermia. However, recent evidence suggests that other therapeutic interventions aimed to minimize progressive deterioration of the brain and other organs function might be helpful to reduce in-hospital mortality and improve neurologic outcome as well as quality of life after cardiac arrest. In this article, we discuss the role of ventilator management on the prognosis after cardiac arrest. We performed a meta-analysis showing that in adult patients not only hypoxia but also hyperoxia was associated with higher in-hospital mortality, while hypercapnia and hypocapnia worse neurologic outcome. In pediatric patients, hypoxia and hyperoxia were not associated with higher in-hospital mortality, while hypocapnia and hypercabia with higher in-hospital mortality worse neurologic outcome. We propose a general bundle for ventilator treatment after cardiac arrest, including: 1) therapeutic hypothermia for 12-24 hours; 2) mean arterial pressure ≥65-75 mmHg; 3) PaO2 between 60-200 mmHg and PCO2 between 30 and 50 mmHg; 4) protective MV with tidal volume of 6-8 mL/kg and positive end expiratory pressure of between 5-10 cmH2O; 5) monitoring of respiratory mechanics, extravascular lung water, hemodynamics, non-invasive transcranial Doppler and intracranial pressure monitoring; and 6) others supportive care, i.e. blood sugar and seizures control.