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Oxygen and carbon dioxide targets after cardiac arrest: an updated systematic review
Mathias J Holmberg1, Takanari Ikeyama2, Rakesh Garg3
1Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
Aim:
To perform an updated systematic review and meta-analysis of oxygen and carbon dioxide targets in patients with sustained return of spontaneous circulation after cardiac arrest.
Methods:
Searches were conducted in MEDLINE, Embase, and Evidence-Based Medicine Reviews from August 2019 to March 2025 for randomised trials comparing specific oxygen or carbon dioxide targets in post-cardiac arrest patients. Two investigators independently reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. The certainty of evidence was evaluated using GRADE methodology.
Results:
Fifteen manuscripts from 12 trials were included. All trials were limited to adult patients, primarily including out-of-hospital cardiac arrests. Five trials evaluated oxygen targets in the prehospital setting, while six evaluated oxygen targets and three evaluated carbon dioxide targets in the intensive care unit setting. Risk of bias was assessed as moderate for most outcomes. Meta-analyses found no differences in survival or favourable functional outcomes when comparing restrictive to liberal oxygen targets in either setting. There was also no difference in outcomes when comparing mild hypercapnia to normocapnia. The certainty of evidence was rated as low to moderate.
Conclusions:
Among patients resuscitated from cardiac arrest, neither restrictive oxygen targets nor mild hypercapnia, compared to conventional targets, improved survival or functional outcomes.
Insights
Neither restrictive oxygen targets nor mild hypercapnia improved survival or functional outcomes in cardiac arrest patients. This systematic review highlights the need for further research on optimal post-cardiac arrest care strategies.
Area of Science:
- Critical Care Medicine
- Cardiology
- Resuscitation Science
Background:
- Optimal management of oxygen and carbon dioxide levels after return of spontaneous circulation (ROSC) following cardiac arrest remains debated.
- Current guidelines offer varied recommendations, necessitating an updated synthesis of evidence.
Purpose of the Study:
- To conduct an updated systematic review and meta-analysis evaluating the impact of specific oxygen and carbon dioxide targets on outcomes in post-cardiac arrest patients.
- To synthesize evidence from randomized trials to inform clinical practice.
Main Methods:
- Systematic searches of MEDLINE, Embase, and Evidence-Based Medicine Reviews (August 2019-March 2025).
- Inclusion of randomized trials comparing oxygen or carbon dioxide targets in adult post-cardiac arrest patients.
- Data extraction, risk of bias assessment (moderate for most outcomes), and meta-analysis using random-effects models.
- Certainty of evidence evaluated using GRADE methodology (rated low to moderate).
Main Results:
- Twelve trials (15 manuscripts) were included, primarily involving out-of-hospital cardiac arrests.
- No significant differences in survival or favorable functional outcomes were found when comparing restrictive versus liberal oxygen targets.
- Mild hypercapnia did not show improved outcomes compared to normocapnia in post-cardiac arrest care.
Conclusions:
- Current evidence suggests that neither restrictive oxygen targets nor mild hypercapnia, when compared to conventional targets, enhance survival or functional outcomes in resuscitated cardiac arrest patients.
- The findings underscore the uncertainty surrounding optimal ventilation and oxygenation strategies in the post-ROSC period.
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