Oxygen and Carbon Dioxide Targets During and After Resuscitation of Cardiac Arrest Patients M

Intensive Care Med (2019) 45:284–286 https://doi.org/10.1007/s00134-018-5456-6

EDITORIAL Oxygen and carbon dioxide targets during and after resuscitation of cardiac arrest patients M. B. Skrifvars1*, T. M. Olasveengen2 and Giuseppe Ristagno3

Introduction minutes [5]. Tere are limited observations of blood Te goal of cardiopulmonary resuscitation (CPR) may and tissue oxygenation and carbon dioxide levels dur- be summarized as an efort to rapidly restore spontane- ing untreated CA in humans, but these levels are likely ous circulation and to prevent hypoxic ischaemic brain infuenced by the pre-arrest factors that determine oxy- injury (HIBI) [1]. Te key determinant of tissue oxygena- gen supply and demand. An asphyxial arrest is expected tion during CPR is high quality chest compressions [2]. to cause lower tissue oxygenation and hypercapnia With ventilation the aim is to increase oxygen content of compared to an arrest from a sudden arrhythmia, as tis- arterial blood whilst decreasing arterial carbon dioxide sue metabolism has continued with decreasing oxygen (paCO2), alleviating respiratory acidosis. On the other supply. Conversely, conditions with decreased oxygen hand, reactive oxygen species play an important part in demand, i.e. hypothermia, will likely yield higher initial the development of HIBI, thus avoiding extreme hyper- tissue oxygenation and lower carbon dioxide compared oxia seems intuitive [3]. Te relationship between arte- to a normothermic arrest. rial and tissue oxygenation and ventilation during CPR In the frst minutes after CA patients may have abnor- is complex. Conclusive evidence of optimal oxygen or mal brainstem mediated breathing, commonly referred carbon dioxide targets are scarce, but taking into account to as “agonal breathing”. Prospective studies have the pathophysiological changes may guide clinical prac- reported agonal breathing in about a third of witnessed tice (Fig. 1). In the current commentary we discuss what out-of-hospital cardiac arrests (OHCA), and found it to is known about the optimal oxygen and carbon dioxide be associated with improved survival [6]. Tis phenom- targets during and immediately after cardiac arrest (CA) enon has also been observed in animal experimental and how we may achieve them. studies, where this agonal respiration has been shown to produce both forward blood fow and ventilation [7]. Changes in oxygen and carbon dioxide in cardiac Although the efectiveness of agonal breathing is uncer- arrest tain, consistent observations that gasping patients have Cardiac arrest causes an abrupt cessation in the delivery better outcomes suggest positive efects on circulation of oxygen, and while many organs may survive hours with and/or gas exchange during CA. ischemia, the brain´s survival is measured in minutes. With high metabolic rates and limited energy stores, Oxygen and carbon dioxide the heart and brain deplete their tissue oxygen within during cardiopulmonary resuscitation seconds [4], and glucose and glycogen reserves within Two elegant studies by Spindelboeck and colleagues investigated oxygen and carbon dioxide levels in arterial blood during CPR in patients ventilated with 100% *Correspondence: [email protected] 1 Department of Emergency Care and Services, University of Helsinki oxygen, describing diferent oxygen levels ranging from and Helsinki University Hospital, Helsinki, Finland hypoxia to hyperoxia [8, 9]. Te study showed that Full author information is available at the end of the article patients with hypoxia had lower survival than those 285

Fig. 1 An approximate depiction of changes in oxygen and carbon dioxide in the arterial blood as well as oxygen in brain tissue before with management aspects, during and immediately after cardiac arrest

with normoxia or hyperoxia, but they could not fnd any pulmonary blood fow may be increased without com- association between oxygenation and bystander CPR or promise of arterial oxygen content or acid–base balance delay from collapse to CPR. Neither did they show any [12]. Tus, the recommendation to ventilate cardiac link between extreme intra-arrest hyperoxia and worse arrest patients with 100% oxygen with a ventilation rate outcomes. Animal data, on the other hand, suggest that of 12 and tidal volume of 500 ml appears justifed, and ventilation with 50% oxygen may be enough to correct in many OHCA cases this will correct the hypoxia; the hypoxia and result in similar levels of brain tissue oxy- efect on paCO2 appears variable. gen compared to 100% oxygen [10]. Teoretically, such a practice could decrease the rate of extreme hyperoxia Oxygen and carbon dioxide targets immediately and should be studied further. One problem is the lack of after ROSC means to monitor intra-arrest oxygenation, since obtain- A sharp increase in mean arterial blood pressure ing an arterial blood gas (ABG) reading appears feasible immediately after ROSC after CA has been commonly only in the intensive care unit (ICU) and in some selected reported. Tis will also increase oxygen levels in brain tis- pre-hospital systems. It may also be argued that venous sue. Te goal at this stage is to monitor oxygenation and samples could be more refective of tissue oxygenation to target normoxia [13]. In the majority of patients, the than arterial samples. Recent studies have addressed percentage of inspired oxygen (FiO2) can be decreased. intra-arrest brain oxygenation monitoring with near Prolonged ventilation with a FiO 2 of 100% is a common infrared spectroscopy (NIRS). Tus far, the evidence does cause of extreme hyperoxia [14]. Even though conclusive not suggest any role for NIRS for tailoring oxygen use evidence does not exist, there is little reason not to avoid during CPR. extreme hyperoxia at this stage. In the only randomized Te studies by Spindelboek also showed that most study conducted to date, Kuisma and colleagues showed patients are hypercapnic during CPR and have severe an increase in neuron specifc enolase (biomarker of respiratory acidosis [8, 9]. Tey did not, however, fnd brain injury) in one subset of patients ventilated with any association between the severity of hypercapnia or 100% compared to 30% [15]. Monitoring oxygenation is acidosis with outcome. Severe acidosis causes negative difcult in the pre-hospital setting, though a small pilot inotropy and vasodilatation which intuitively appears trial using peripheral oxygen saturation to titrate oxy- harmful. Ventilation with higher minute volumes can gen found this strategy resulted in frequent hypoxia [16]. decrease paCO2 quicker and normalize pH but this has Tus, there is a need for obtaining an arterial blood gas inadvertent efects. An important study by Aufderheide reading as soon as possible. and colleagues showed that hyperventilation during CPR In most cases, paCO2 is elevated after ROSC. Tis will increases intra-thoracic pressure, decrease coronary per- correct itself over the frst hour and there is little need fusion pressure and worsens outcome [11]. By decreas- to speed up this process; some clinical data even sug- ing the frequency of ventilations, cardiac output and gest associations between moderate hypercapnia and 286

improved outcome [17]. Indeed paCO is an important 6. Debaty G, Labarere J, Frascone RJ, Wayne MA, Swor RA, Mahoney BD, 2 Domeier RM, Olinger ML, O’Neil BJ, Yannopoulos D, Aufderheide TP, Lurie regulator of cerebral blood fow and moderate hyper- KG (2017) Long-term prognostic value of gasping during out-of-hospital capnia can, according to experimental studies and one cardiac arrest. J Am Coll Cardiol 70:1467–1476 clinical pilot study, increase cerebral oxygenation and 7. Ristagno G, Tang W, Sun S, Weil MH (2007) Spontaneous gasping pro- duces carotid blood fow during untreated cardiac arrest. Resuscitation attenuate ischaemia-reperfusion injury due to mitiga- 75:366–371 tion of oxidative stress [18, 19]. Animal data also sug- 8. Spindelboeck W, Schindler O, Moser A, Hausler F, Wallner S, Strasser C, gest antiepileptic efects with moderate hypercapnia and Haas J, Gemes G, Prause G (2013) Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved potential reduction in the excitotoxicity induced by high rates of hospital admission. Resuscitation 84:770–775 levels of excitatory neurotransmitters such as the amino 9. Spindelboeck W, Gemes G, Strasser C, Toescher K, Kores B, Metnitz P, Haas acid glutamate [20]. Two ongoing large RCTs, one on J, Prause G (2016) Arterial blood gases during and their dynamic changes after cardiopulmonary resuscitation: a prospective clinical study. Resusci- oxygen use during tranportation of OHCA patients (the tation 106:24–29 EXACT trial, NCT3138005) and one on targeting mild 10. Nelskyla A, Nurmi J, Jousi M, Schramko A, Mervaala E, Ristagno G, Skrifvars hypercapnia during the frst 24 h of ICU care (the TAME MB (2017) The efect of 50% compared to 100% inspired oxygen fraction on brain oxygenation and post cardiac arrest mitochondrial function in trial, NCT3114033) are ongoing and are likely to provide experimental cardiac arrest. Resuscitation 116:1–7 more conclusive evidence. Until conclusive clinical data 11. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von are made available, the current recommendation is to Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG (2004) Hyperventila- tion-induced hypotension during cardiopulmonary resuscitation. Circula- aim for normoventilation with a paO 2 of 4.5–6.0 kPa [13]. tion 109:1960–1965 12. Yannopoulos D, Tang W, Roussos C, Aufderheide TP, Idris AH, Lurie KG (2005) Reducing ventilation frequency during cardiopulmonary resuscita- Author details tion in a porcine model of cardiac arrest. Respir Care 50:628–635 1 Department of Emergency Care and Services, University of Helsinki and Hel- 13. Soar J, Nolan JP, Bottiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni 2 sinki University Hospital, Helsinki, Finland. Department of Anesthesiology, C, Skrifvars MB, Smith GB, Sunde K, Deakin CD, Adult Advanced Life 3 Oslo University Hospital, Oslo, Norway. Neurosurgery I Unit, Neuro Center, Support Section C (2015) European Resuscitation Council guidelines for Humanitas Research Hospital, Rozzano, Italy. resuscitation 2015: section 3. Adult advanced life support. Resuscitation 95:100–147 Compliance with ethical standards 14. Nelskyla A, Parr MJ, Skrifvars MB (2013) Prevalence and factors correlat- ing with hyperoxia exposure following cardiac arrest—an observational Conflicts of interest single centre study. Scand J Trauma Resusc Emerg Med 21:35 Markus Skrifvars has received a lecture fee from Covidien (Invos). 15. Kuisma M, Boyd J, Voipio V, Alaspaa A, Roine RO, Rosenberg P (2006) Comparison of 30 and the 100% inspired oxygen concentrations during early post-resuscitation period: a randomised controlled pilot study. Received: 10 September 2018 Accepted: 7 November 2018 Resuscitation 69:199–206 Published online: 12 November 2018 16. Young P, Bailey M, Bellomo R, Bernard S, Dicker B, Freebairn R, Henderson S, Mackle D, McArthur C, McGuinness S, Smith T, Swain A, Weatherall M, Beasley R (2014) HyperOxic Therapy OR NormOxic Therapy after out-of- hospital cardiac arrest (HOT OR NOT): a randomised controlled feasibility References trial. Resuscitation 85:1686–1691 1. Nolan JP, Berg RA, Callaway CW, Morrison LJ, Nadkarni V, Perkins GD, 17. Vaahersalo J, Bendel S, Reinikainen M, Kurola J, Tiainen M, Raj R, Pettila V, Sandroni C, Skrifvars MB, Soar J, Sunde K, Cariou A (2018) The present and Varpula T, Skrifvars MB, Group FS (2014) Arterial blood gas tensions after future of cardiac arrest care: international experts reach out to caregivers resuscitation from out-of-hospital cardiac arrest: associations with long- and healthcare authorities. Intensive Care Med 44:823–832 term neurologic outcome. Crit Care Med 42:1463–1470 2. Imberti R, Bellinzona G, Riccardi F, Pagani M, Langer M (2003) Cerebral 18. Eastwood GM, Young PJ, Bellomo R (2014) The impact of oxygen and perfusion pressure and cerebral tissue oxygen tension in a patient during carbon dioxide management on outcome after cardiac arrest. Curr Opin cardiopulmonary resuscitation. Intensive Care Med 29:1016–1019 Crit Care 20:266–272 3. Neumar RW (2011) Optimal oxygenation during and after cardiopulmo- 19. Shoja MM, Tubbs RS, Shokouhi G, Loukas M, Ghabili K, Ansarin K (2008) nary resuscitation. Curr Opin Crit Care 17:236–240 The potential role of carbon dioxide in the neuroimmunoendocrine 4. MacMillan V, Siesjo BK (1971) Critical oxygen tensions in the brain. Acta changes following cerebral ischemia. Life Sci 83:381–387 Physiol Scand 82:412–414 20. Tolner EA, Hochman DW, Hassinen P, Otahal J, Gaily E, Haglund MM, 5. Siesjo BK, Carlsson C, Hagerdal M, Nordstrom CH (1976) Brain metabolism Kubova H, Schuchmann S, Vanhatalo S, Kaila K (2011) Five percent CO(2) in the critically ill. Crit Care Med 4:283–294 is a potent, fast-acting inhalation anticonvulsant. Epilepsia 52:104–114