May - 2017
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Favorable Neurocognitive Outcome with Low Tidal Volume Ventilation after Cardiac Arrest
Am J Resp Crit Care Med, 2017, 195(9);1198-1206
There is increasing interest about ventilatory management following out of hospital cardiac arrest (OHCA), with trials underway or proposed looking at CO2 and )2 management. This propensity adjusted two-centre retrospective analysis examines the association of tidal volume and neurocognitive outcome after OHCA.
They identified 256 adults with OHCA (76% witnessed, 51% VF/VT), who required MV for greater than 48-hrs, from 2008-2014, and calculated time-weighted average Vt over the first 48 hours of MV. The primary outcome was favourable hospital outcome at hospital discharge (CPC 1,2), ascertained by blinded physician investigators. The exposure of interest, tidal volume, was analysed as a continuous variable, and a dichotomised variable (less than or greater than 8 ml/kg PBW), with a propensity score developed using logistic regression to estimate the risk of receiving high or low Vt.
Overall this retrospective study reported lower Vt after OHCA was independently associated with favorable neurocognitive outcome, more ventilator-free days, and more shock-free days. These findings suggest low-Vt ventilation after cardiac arrest is beneficial. Although it is limited by methodology, it is difficult to imagine the justification for a prospective study with a "high Vt" arm. So should we just practice low Vt in OHCA?
Rationale: Neurocognitive outcome after out-of-hospital cardiac arrest (OHCA) is often poor, even when initial resuscitation succeeds. Lower tidal volumes (Vts) attenuate extrapulmonary organ injury in other disease states and are neuroprotective in preclinical models of critical illness.
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