ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
ALS 448 OXYGEN DOSE AFTER ROSC IN ADULTS
CoSTR Statement
PICO
•
P - Among adults who have ROSC after cardiac arrest in any setting
•
I - Does an inspired oxygen concentration titrated to oxygenation
(normal oxygen saturation or partial pressure)
•
C - Compared with the use of 100% inspired oxygen
•
O – change:
•
Survival with favorable neurological/functional outcome at discharge,
30 days, 60 days, 180 days AND/OR 1 year (9-critical outcome),
•
Survival at discharge, 30 days, 60 days, 180 days AND/OR 1 year (8critical outcome)?
•
ICU survival (5- important)?
Existing 2010 CoSTR/Guidelines
2010 ILCOR TR: There is insufficient clinical evidence to support or refute the
use of inspired oxygen concentration titrated to arterial blood oxygen saturation
in the early care of cardiac arrest patients following sustained ROSC.
2010 AHA Guideline: Although 100% oxygen may have been used during initial
resuscitation, providers should titrate inspired oxygen to the lowest level
required to achieve an arterial oxygen saturation of 94%, so as to avoid potential
oxygen toxicity. It is recognised that titration of inspired oxygen may not be
possible immediately after out-of-hospital cardiac arrest until the patient is
transported to the emergency department or, in the case of in-hospital arrest, the
intensive care unit (ICU).
2010 ERC Guideline: In clinical practice, as soon as arterial blood oxygen
saturation can be monitored reliably (by blood gas analysis and/or pulse
oximetry), it may be more practicable to titrate the inspired oxygen
1
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
concentration to maintain the arterial blood oxygen saturation in the range of
94–98%.
Evidence from 10 studies included (up 7 December 2014):
1. 1 RCT [Kuisma 2006 199] of 30% inspired oxygen for 60 minutes after ROSC
vs. 100% inspired oxygen for 60 minutes after ROSC.
2. 9 observational studies:
a. 2 studies [Kilgannon 2010 2165, Roberts 2013 2107] of first ICU PaO2
(hyperoxia vs. normoxia).
b. 1 study [Kilgannon 2010 2165] of first ICU PaO2 (hypoxia vs.
normoxia).
c. 2 studies [Kilgannon 2011 2717, Ihle 2013 186] of worse
(highest/lowest) PaO2 in first 24 h after ICU admission/arrest
(hyperoxia vs. normoxia).
d. 1 study [Bellomo 2011 R90] of worse PaO2 in first 24 h after ICU
admission (hyperoxia vs. normoxia) (hypoxia vs. normoxia).
e. 1 study [Janz 2012 3135] of highest PaO2 in first 24 h after arrest
(association of maximum PaO2 and survival).
f. 1 study [Nelskyla 20131] of PaO2 in first 24 after arrest (hyperoxia vs.
not hyperoxia).
g. 1 study [Vaahersalo 2014 1463] looking at mean, highest and lowest
PaO2 in first 24 h of ICU.
h. 1 study [Elmer 20142] looking at oxygen exposure over first 24 h of
ventilation.
Definitions of hyperoxia/normoxia/hypoxia used
See table at end .
1
2
doi: 10.1186/1757-7241-21-35
doi:10.1007/s00134-014-3555-6
2
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Consensus on Science
1. 30% inspired oxygen for 60 minutes after ROSC vs. 100% inspired
oxygen for 60 minutes after ROSC
Survival to discharge with favourable neurological outcome (CPC 1 or 2):
[1 study, observational, Kuisma 2006 199].
For the critical outcome of survival to hospital discharge with favourable
neurological outcome (CPC 1 or 2) we have identified very low quality evidence
(downgraded for small numbers, lack of blinding, indirectness, misallocation of
patients) from one RCT [Kuisma 2006 199] enrolling 32 OHCA (of which 4
excluded) patients that showed no difference between 30% inspired oxygen for
60 minutes after ROSC vs.100% inspired oxygen for 60 minutes after ROSC
(8/14 vs. 6/14, unadjusted RR for survival1.33 [95% CI 0.63 to 2.84] p=0.46)3.
Survival to hospital discharge:
[1 study, observational, Kuisma 2006 199].
For the critical outcome of survival to hospital discharge we have identified very
low quality evidence (downgraded for small numbers, lack of blinding,
indirectness, misallocation of patients) from one RCT [Kuisma 2006 199]
enrolling 32 OHCA (of which 4 excluded) patients that showed no difference
between 30% inspired oxygen for 60 minutes after ROSC and 100% inspired
oxygen for 60 minutes of after ROSC (10/14 vs. 10/14, unadjusted RR for
survival 1.0 [95% CI 0.63 to 1.60] p=1.00).
2. Hyperoxia vs. Normoxia
Survival with favourable neurological outcome (CPC 1 or 2) at 12 months:
[1 study , observational, Vaahersalo 2014 1463]
Unadjusted relative risk calculated using
http://www.medcalc.org/calc/relative_risk.php
3
3
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
For the critical outcome of survival with favourable neurological outcome (CPC 1
or 2) at 12 months we have identified very low quality evidence from 1 study
[Vaahersalo 2014 1463] (downgraded for very serious risk of bias, and
indirectness) that showed no harmful effect from hyperoxia during the first 24
hours of ICU care.
Survival to discharge with favourable neurological outcome (CPC 1 or 2):
[5 studies, observational, Kilgannon 2010 2165, Bellomo 2011 R90, Janz 2012
3135, Roberts 2013 2107, Elmer 2014]
For the critical outcome of survival to hospital discharge with favourable
neurological outcome (CPC 1 or 2) we have identified very low quality evidence
(downgraded as very serious bias and serious inconsistency, indirectness,
confounding)) from 5 observational studies with conflicting results [2 showed
hyperoxia worse than normoxia]. Studies reported CPC 1 or 2 outcomes at
discharge:

Janz [2012 3135] showed in a single centre study of 170 ICU patients treated
with therapeutic hypothermia that the maximum PaO2 in the first 24 h after
arrest was associated with a worse outcome (CPC 1 or 2) (poor neurological
status at hospital discharge, adjusted OR 1.485 [95% CI1.032– 2.136] P =
.033).

Roberts [2013 2107] showed in a single centre study of 193 ICU patients that
the first PaO2 after ROSC was not associated with outcome (hyperoxia
adjusted OR for poor neurological outcome 1.05 [95% CI 0.45-2.42]
P=0.911).

Elmer [2014] showed in a single centre study of 184 ICU patients that
oxygen exposure over first 24 h of ventilation was not associated with
outcome with unadjusted and adjusted outcomes [effect size cannot be
estimated from data].
Two studies did not report CPC outcomes, and used other measures as a
surrogate marker:
4
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015

Kilgannon [2010 2165] reported worse independent functional survival
at hospital discharge (hyperoxia vs. normoxia 124/1156 vs. 245/1171
[29 vs. 38%], unadjusted OR 0.45 [95%CI 0.36 -0.58] P<0.0001).

Bellomo [2011 R90] reported no difference in discharge to home
[hyperoxia vs. normoxia (27 vs. 34%) - effect size cannot be estimated
from data]
Survival to hospital discharge (or survival to 30 days):
[7 observational studies, Kilgannon 2010 2165, Kilgannon 2011 2717, Bellomo
2011 R90, Janz 2012 3135, Ihle 2013 186, Nelskyla 2013, Elmer 2014]
For the critical outcome of survival to discharge (or survival to 30 days) we have
identified very low quality evidence (downgraded as very serious bias and
serious inconsistency, indirectness, confounding) from 7 observational studies
with conflicting results [4 showed hyperoxia worse than normoxia].

Kilgannon [2010 2165] showed a worse outcome with hyperoxia vs.
normoxia based on the first ICU PaO2 (in-hospital mortality 63 vs. 45%,
adjusted OR hyperoxia exposure 1.8 [95% CI 1.5-2.2 P = 0 .001]).

Kilgannon [2011 2717] showed a 100 mm Hg increase in PaO2 was
associated with a 24% increase in mortality risk (odds ratio 1.24 [95%
confidence interval 1.18 to 1.31]).

Bellomo [2011 R90] showed no association between hyperoxia vs. normoxia
(based on the worse PaO2 in first 24 h on ICU) adjusted OR for hospital
mortality of 1.2 (95% CI 1.0 to 1.5) P= 0.04).

Janz [2012 3135] showed in a single centre study of 170 ICU patients treated
with therapeutic hypothermia that the maximum PaO2 in the first 24 h after
arrest was associated with a worse outcome. Survivors had lower maximum
PaO2 (198 mm Hg; interquartile range, 152.5–282) vs. non survivors (254
mm Hg; interquartile range, 172–363; p =0.022). Adjusted OR - higher PaO2
increased in-hospital mortality (odds ratio 1.439; 95% CI 1.028–2.015; P =
.034).
5
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015

Ihle [2013 186] showed in a data linkage study of worse PaO2
(highest/lowest) in first 24 on ICU hyperoxia was not associated with
outcome (hospital mortality 47 vs. 41%, adjusted OR hyperoxia vs. normoxia
1.2 [95%CI 0.51 -2.82]).

Nelskyla [2013] enrolling 122 ICU admissions patients that showed no
difference between patients with hyperoxia (PaO2 > 300mmHg in 1st 24 h
after arrest) and normoxia (22/49 vs. 25/70, unadjusted OR 0.68 [95% CI
0.32 to 1.44] P=0.31) for 30 day survival or survival to discharge (20/49 vs.
24/70, unadjusted OR 0.76 [95% CI 0.36 to 1.61] P=0.47).

Elmer [2014] reported that of 184 ICU patients, 36 % were exposed to severe
hyperoxia, there overall mortality was 54 %, and severe hyperoxia, was
associated with decreased survival in both unadjusted and adjusted analysis
[adjusted odds ratio (OR) for survival 0.83 per hour exposure (95% CI 0.690.990, P = 0.04].
Survival to ICU discharge:
[2 observational studies, Ihle 2013 186, Nelskyla 2013]
For the important outcome of survival to ICU discharge we have identified very
low quality evidence (downgraded as very serious bias, serious indirectness,
confounding) from 2 observational studies that showed no harm from hyperoxia:

Ihle [2013 186] showed in a data linkage study of worse PaO2
(highest/lowest) in first 24 on ICU hyperoxia was not associated with
outcome (ICU mortality 35% vs. 32% for hyperoxia vs. normoxia, unadjusted
OR 1.16 [95%CI 0.56 – 2.40] P=0.68).

One observational study [Nelskyla 2013, survival to 30 days] enrolling 122
ICU admissions patients that showed no difference between patients with
hyperoxia (PaO2 > 300mmHg in 1st 24 h after arrest) and normoxia (ICU
discharge 53% vs. 46%, adjusted OR 0.75 [95%CI 0.36-1.55] P=0.43).
3. Hypoxia vs. normoxia
Survival to hospital discharge (or survival to 30 days):
6
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
[3 observational studies, Kilgannon 2010 2165, Bellomo 2011 R90, Ihle 2013 186]
For the critical outcome of survival to discharge (or survival to 30 days) we have
identified very low quality evidence (downgraded as very serious bias and
serious indirectness, confounding) from 3 observational studies that showed :

Kilgannon [2010 2165] showed a worse outcome with hypoxia vs. normoxia
based on the first ICU PaO2 (57 vs. 45%, adjusted OR hypoxia exposure 1.3
[95%CI 1.1-1.5] P = 0.009).

Bellomo [2011 R90] showed a hypoxia vs. normoxia (based on the worse
PaO2 in first 24 h on ICU) hospital mortality of 60 vs. 47% (hypoxia/poor O2
exchange vs. normoxia, OR hospital mortality 1.2 (1.1 to 1.4) P= 0.002).
This paper also reported discharge to home outcomes (hypoxia/poor O2
exchange vs. normoxia 26 vs. 24%).

Ihle [2013 186] showed in a data linkage study of worse PaO2
(highest/lowest) in first 24 on ICU no difference in outcome between hypoxia
and normoxia (for in hospital mortality, 51 vs. 41%, adjusted OR hypoxia vs.
normoxia 0.93 [95%CI 0.47-1.87].
Survival to ICU discharge:
[1 observational study, Ihle 2013 186]
For the important outcome of survival to ICU discharge we have identified very
low quality evidence (downgraded as very serious bias and serious indirectness,
confounding) from 1 observational study:

Ihle [2013 186] showed in a data linkage study of worse PaO2
(highest/lowest) in first 24 on ICU hypoxia was associated with a worse
unadjusted outcome (ICU mortality 49% vs. 32% for hypoxia vs. normoxia,
unadjusted OR 2.15 [95% CI 1.23 – 3.77] P=0.008). RR 0.74 (95% CI 0.56 0.96) – worse with hypoxia.
7
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Treatment recommendation (Initially proposed)

We suggest the use of titrated inspired oxygen aiming at normoxia
(arterial oxygen saturation 94-98%) in adults with ROSC after cardiac
arrest in any setting.

We suggest the use of 100% inspired oxygen until arterial oxygen
saturation or the partial pressure of arterial oxygen can be measured
reliably in adults with ROSC after cardiac arrest in any setting.
Treatment recommendation after TF webinar on 18 July 2014
Main feeling was that hypoxia is still bad for you, normoxia OK, and hyperoxia
could be bad, and that we should not be prescriptive regarding a target oxygen
saturation.
•
We recommend the avoidance of hypoxia in adults with ROSC after
cardiac arrest in any setting (strong recommendation, very low quality
evidence).
•
We suggest the avoidance of hyperoxia in adults with ROSC after cardiac
arrest in any setting (weak recommendation, very low quality
evidence).
•
We suggest the use of 100% inspired oxygen until the arterial oxygen
saturation or the partial pressure of arterial oxygen can be measured
reliably in adults with ROSC after cardiac arrest in any setting (weak
recommendation, very low quality evidence).
Considerations
In making these recommendations, we think despite the very low quality
evidence there is likely to be far greater actual harm from hypoxia and therefore
make a strong recommendation that hypoxia should be avoided. The evidence
8
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
for harm associated with hyperoxia is of very low quality and inconsistent hence
the weak recommendation.
Knowledge gaps
1. Is it feasible to assess arterial oxygenation after ROSC?
2. Can inspired oxygen be titrated immediately after ROSC?
3. What is the optimum arterial oxygenation
a. Immediately after ROSC?
b. In first 24, 48 or 72 h after ROSC?
4. How is arterial oxygenation assessed in studies
a. SaO2 vs. PaO2?
b. Serial readings of SaO2?
c. Highest lowest readings?
SEARCH strategy details
PubMed: ( Search Completed: November 26, 2013 ) PubMed 614
((((((((((((((((rosc) OR heart arrest[MeSH Terms]) OR cardiopulmonary
resuscitation[MeSH Terms]) OR Spontaneous circulation) OR post resuscitation)
OR post cardiac arrest))) OR ((blood circulation[MeSH Terms]) AND recovery of
function))))) AND ((("oxygen inhalation therapy"OR Hyperoxia [mh] OR
"hyperoxic"[tiab] OR “supranormal”[tiab] OR "normoxic"[tiab] OR
“titrated”[tiab] OR "oxygen"[tiab]) OR hyperoxia [mh] OR Hypercapnia[mh])))
AND (((((((((((((("randomized controlled trial"[PT] OR "controlled clinical
trial"[PT] OR "clinical trial"[PT] OR "comparative study"[PT] OR random*[TIAB]
OR controll*[TIAB] OR "intervention study"[TIAB] OR "experimental
study"[TIAB] OR "comparative study"[TIAB] OR trial[TIAB] OR evaluat*[TIAB]
OR "Before and after"[TIAB] OR "interrupted time series"[TIAB]))) OR
(("Epidemiologic Studies"[Mesh] OR "case control"[TIAB] OR "casecontrol"[TIAB] OR ((case[TIAB] OR cases[TIAB]) AND (control[TIAB] OR
controls[TIAB)) OR "cohort study"[TIAB] OR "cohort analysis"[TIAB] OR "follow
up study"[TIAB] OR "follow-up study"[TIAB] OR "observational study"[TIAB] OR
"longitudinal"[TIAB] OR "retrospective"[TIAB] OR "cross sectional"[TIAB] OR
"cross-sectional"[TIAB] OR questionnaire[TIAB] OR questionnaires[TIAB] OR
survey[TIAB])))) NOT (("animals"[MH] NOT (animals[MH] AND
"humans"[MH])))) NOT (("letter"[pt] OR "comment"[pt] OR "editorial"[pt]))))
AND English[lang]))))))))
9
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Embase: ( Search Completed: November 26, 2013 ) rosc:ab,ti OR 'return of
spontaneous circulation':ab,ti OR 'heart arrest'/exp OR 'resuscitation'/exp AND
('oxygen'/exp AND 'therapy'/exp OR 'hyperoxia'/exp OR supranormal:ab,ti OR
normoxic:ab,ti OR 'titrated oxygen') NOT ('animal'/exp NOT 'human'/exp) NOT
([editorial]/lim OR [letter]/lim OR 'case report'/exp) AND [embase]/lim
Cochrane: ( Search Completed: November 26, 2013 ) ROSC:ti,ab or "return of
spontaneous circulation":ti,ab or [mh "Cardiopulmonary Resuscitation"] or [mh
Resuscitation] and ([mh "oxygen therapy"] or [mh hyperoxia] or
"supranormal":ab,ti or normoxic:ab,ti or "titrated oxygen":ab,ti)
Other: ( Search Completed: )
Main Topics/Key Terms:
Key Authors: Kilgannon JH
Bellomo R
Janz DR
Kuisma M
Key Articles: Bellomo R, Bailey M, Eastwood GM, Nichol A, Pilcher D, Hart GK, . . .
Cooper DJ. Arterial hyperoxia and in-hospital mortality after resuscitation from
cardiac arrest. Crit Care 2011; 15 (2): R90
Janz DR, Hollenbeck RD, Pollock JS, McPherson JA and Rice TW. Hyperoxia is
associated with increased mortality in patients treated with mild therapeutic
hypothermia after sudden cardiac arrest. Critical Care Medicine 2012;
Kilgannon JH, Jones AE, Parrillo JE, Dellinger RP, Milcarek B, Hunter K, . . .
Trzeciak S. Relationship between supranormal oxygen tension and outcome after
resuscitation from cardiac arrest. Circulation 2011; 123 (23): 2717-22
Kuisma M, Boyd J, Voipio V, Alaspaa A, Roine RO and Rosenberg P. Comparison of
30 and the 100% inspired oxygen concentrations during early post-resuscitation
period: a randomised controlled pilot study. Resuscitation 2006; 69 (2): 199-206
Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, Parrillo JE,
Trzeciak S; Emergency Medicine Shock Research Network (EMShockNet)
Investigators. Association between arterial hyperoxia following resuscitation
from cardiac arrest and in-hospital mortality.
JAMA. 2010 Jun 2;303(21):2165-71.
Inclusion/Exclusion Criteria: Exclude animal studies
Exclude paediatric studies
10
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
1st Author
Kilgannon
Kilgannon
Year
Hyperoxia
Hypoxia
Values used
2010
PaO2 ≥ 300 mmHg
PaO2 < 60 mmHg or
PaO2/FiO2 < 300)
First arterial blood gas (ABG) during first 24 h on ICU
2011
Not defined, used
ascending
ranges of oxygen tension
(PaO2 60 to 99, 100 to
199, 200 to 299, 300
to 399, and ≥ 400 mmHg)
PaO2 < 60 mm Hg or severe
oxygenation impairment
Defined the exposure by the highest partial pressure of arterial
(defined as a highest
oxygen (PaO2) over the first 24 hours in the ICU.
PaO2/FiO2 < 200)
PaO2 ≥ 300 mmHg
All ABGs during first 24 hours of ICU entered into data collection
system which automatically selects the appropriate high and low
hypoxia/poor O2 transfer
simultaneous FiO2 and PaO2 measurements and deletes other
as either PaO2 < 60 mmHg oxygenation data. Using the APACHE II/ III methodology for
or a P/F ratio <300. Isolated intubated patients with FiO2 ≥0.5, the PaO2 associated with the
hypoxemia as PaO2 < 60
arterial blood gas with the highest (A-a) gradient is selected as the
mmHg regardless of FiO2
index of worst oxygenation. For nonintubated patients or
level.
intubated patients with FiO2 < 0.5, the lowest arterial blood gas
PaO2 level
is recorded.
Bellomo
2011
Janz
Ihle
2012
2013
PaO2 ≥ 300mmHg
PaO2 < 60mmHg
Nelskyla
2013
PaO2 ≥ 300 mmHg
PaO2 < 60mmHg
Roberts
2013
PaO2 ≥ 300 mmHg
Not defined
Median, Max PaO2 in first 24 h after cardiac arrest used
First 24 hours ICU admission APACHE III PaO2 level (as Bellomo)
Highest arterial oxygen value measured during the first 24 h after
cardiac arrest.
First ABG after ROSC
11
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Vaahersalo
Elmer
2014
2014
Pao2 low (< 75 mm Hg), Pao2 middle (75–150 mm Hg),
Pao2 intermediate (150– 225 mm Hg), Pao2 high (> 225
mm Hg), We defined hyperoxia as Pao2 > 300 mm Hg
All ABG during the first 24 h after ICU admission. Used the first
measured Pao2 values to represent the time from admission to
first measurement. Calculated time intervals between ABG
measurements and assumed that Pao2 values remained
constant at the levels observed in the previous measurement
until the time point of the next measurement. Calculated
the proportion of time spent in different oxygen categories
during the first 24 hours. Thus, during the first 24 hours, patients
had oxygen values that fell in several categories and for each
patient time spent in each of the predefined categories ranged
from 0% to 100%.
Severe Hyperoxia = PaO2
≥ 300 mmHg Moderate
hyperoxia = PaO2 101 299 mmHg
If no data were available for a
longer period, we used oxygen saturation (SpO2) to
classify patients as having ‘‘hypoxia’’ (SpO2\90 %);
‘‘normoxia’’ (SpO2 = 90–99 % or 100 % when FiO2 =
0.4); or ‘‘probable hyperoxia’’ (SpO2 = 100 % and
FiO2[0.4) . We defined ‘‘probable hyperoxia’’ this
way because we observed a mean PaO2:FiO2 ratio of 240,
which yields a PaO2 of 96 mmHg (i.e. the upper limit of
‘‘normoxia’’) in a patient with an SaO2 of 100 % and
FiO2 = 0.4. For each category of oxygen exposure, we
summed the total number of hours spent at that level in
the first 24 h, to generate four continuous predictor variables
that could range from 0 to 24 h. We used these
continuous predictors in our unadjusted models and
adjusted models that would include only a single oxygen
exposure category predictor.
PaO2 < 60mmHg
12
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Criteria
Additional
considerations
Research evidence
Judgements
● No
○
Probably
no
Problem
Is there a
problem
priority?
○
Uncertain
○
Probably
yes
○ Yes
○ Varies
○ No
included
studies
Benefits &
harms of
the options
What is the
overall
certainty of
this
evidence?
○ Very
The relative importance or values of the main outcomes of interest:
Outcome
Relative
importance
low
● Low
○
Certainty of the
evidence
(GRADE)
Survival to 30 days
CRITICAL
⨁◯◯◯
Survival to discharge with favourable
neurological/functional outcome
CRITICAL
⨁◯◯◯
Survival to discharge with favourable
neurological/functional outcome
CRITICAL
⨁◯◯◯
VERY LOW
Moderate
○ High
Is there
important
uncertainty
about how
much people
value the
○
Important
uncertainty
or
variability
VERY LOW
VERY LOW
13
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
main
outcomes?
○ Possibly
important
uncertainty
or
variability
○
Probably
no
important
uncertainty
of
variability
Survival to discharge
CRITICAL
⨁◯◯◯
Survival to discharge
CRITICAL
⨁◯◯◯
ICU survival
IMPORTANT
⨁◯◯◯
VERY LOW
VERY LOW
VERY LOW
● No
important
uncertainty
of
variability
○ No
known
undesirable
Are the
desirable
anticipated
effects large?
Summary of findings: 100% inspired oxygen
Outcome
Without use
of an FiO2
titrated to
oxygenation
With use of
an FiO2
titrated to
oxygenation
Difference
(95% CI)
Relative
effect
(RR)
(95%
CI)
○ No
○
Survival to 30 days
not
estimable
not
estimable
Probably
no
Survival to discharge
with favourable
neurological/functional
outcome
not
estimable
not
estimable
Survival to discharge
with favourable
neurological/functional
outcome
not
estimable
not
estimable
●
Uncertain
○
Probably
yes
○ Yes
○ Varies
14
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
○ No
○
Probably
no
Are the
undesirable
anticipated
effects small?
●
Survival to discharge
not
estimable
not
estimable
Survival to discharge
not
estimable
not
estimable
ICU survival
not
estimable
not
estimable
Uncertain
○
Probably
yes
○ Yes
○ Varies
○ No
○
Are the
desirable
effects large
relative to
undesirable
effects?
Probably
no
●
Uncertain
○
Probably
yes
○ Yes
○ Varies
Resource
use
Are the
resources
required
small?
○ No
○
Probably
no
15
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
○
Uncertain
●
Probably
yes
○ Yes
○ Varies
○ No
○
Is the
incremental
cost small
relative to
the net
benefits?
Probably
no
●
Uncertain
○
Probably
yes
○ Yes
○ Varies
○
Increased
Equity
What would
be the impact
on health
inequities?
○
Probably
increased
○
Uncertain
●
Probably
16
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
reduced
○
Reduced
○ Varies
○ No
○
This is in line with the current guidelines
Probably
no
Acceptability
Is the option
acceptable to
key
stakeholders?
○
Uncertain
○
Probably
yes
● Yes
○ Varies
○ No
○
Yes as rec
Probably
no
Feasibility
Is the option
feasible to
implement?
○
Uncertain
○
Probably
yes
● Yes
○ Varies
17
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Recommendation
Should use of an FiO2 titrated to oxygenation vs. 100% inspired oxygen be used for adults with ROSC after cardiac arrest
in any setting?
Balance of
consequences
Undesirable consequences
clearly outweigh desirable
consequences in most settings
Undesirable consequences
probably outweigh desirable
consequences in most settings
The balance between desirable and
undesirable consequences is
closely balanced or uncertain
Desirable consequences probably
outweigh undesirable
consequences in most settings
Desirable consequences clearly
outweigh undesirable
consequences in most settings
○
○
●
○
○
Type of recommendation
We recommend against offering this option
We suggest not offering this option
We suggest offering this option
We recommend offering this option
○
○
●
○
We recommend the avoidance of hypoxia in adults with ROSC after cardiac arrest in any setting.
Recommendation
We suggest the avoidance of hyperoxia in adults with ROSC after cardiac arrest in any setting.
We suggest the use of 100% inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be
measured reliably in adults with ROSC after cardiac arrest in any setting.
This is similar to 2010 guidelines.
Justification
There is no evidence of harm from targeting normoxia.
Subgroup considerations
Adult patients with ROSC in any setting
18
ALS 448 Oxygen dose after ROSC in adults
Soar/Donnino CoSTR 3 January 2015
Implementation
considerations
This is only feasible when oxygenation can be measured reliably (by pulse oximetry or blood gas analysis).
Monitoring and
evaluation
Feasibility of monitoring oxygen levels immediately after ROSC, especially in prehospital not known
There is a need for a randomised study comparing different oxygen strategies after ROSC
Research possibilities
Defining normoxia.
19