NEJM: No Benefit to Higher or Lower Blood Pressure and Oxygen Targets in Comatose Patients After Cardiac Arrest

Patricia Kritek, MD, reviewing 

In a large trial, similar numbers of patients had poor outcomes regardless of targeting strategy.

Oxygen delivery to the brain is essential after cardiac arrest. Inadequate perfusion worsens ischemic injury; however, animal models suggest that hyperoxia also can be harmful. Evidence is limited for blood pressure and oxygenation goals for patients who are comatose after cardiac arrest; two recent large trials showed no benefit for conservative oxygenation (NEJM JW Gen Med Mar 1 2021 and N Engl J Med 2021; 384:1301; NEJM JW Dec 15 2019 and N Engl J Med 2020; 382:989).

Danish investigators randomized nearly 800 comatose survivors of out-of-hospital cardiac arrest to a mean arterial pressure (MAP) target of 63 mm Hg or 77 mm Hg during their intensive care unit stay and also, in a 2×2 factorial design, to a restrictive or liberal oxygenation target (partial pressure of oxygen [PaO2], 68–75 mm Hg or 98–105 mm Hg, respectively). Most patients had shockable rhythms and witnessed arrests with bystander resuscitation. All patients had targeted temperature management to 36°C for 24 hours. Volume resuscitation, vasopressor administration, and oxygen titration were protocolized.

The protocol achieved good between-group separation in mean MAP (difference, 11 mm Hg), mean PaO2, and mean fraction of inspired oxygen. Similar numbers of patients in all groups (32%–34%) were discharged from the hospital with poor neurological outcome or died at 90 days. No interaction between interventions was noted.

COMMENT

This trial showed no evidence of benefit for a specific MAP or oxygenation goal for comatose patients after out-of-hospital cardiac arrest. Despite the theoretical benefit of higher blood pressure or lower oxygen levels, I will continue my practice of maintaining MAP >65 mm Hg and keeping oxygen saturations in the low to mid 90s.

CITATIONS

Schmidt H et al. Oxygen targets in comatose survivors of cardiac arrest. N Engl J Med 2022 Aug 27; [e-pub]. (https://doi.org/10.1056/NEJMoa2208686)

Kjaergaard J et al. Blood-pressure targets in comatose survivors of cardiac arrest. N Engl J Med 2022 Aug 27; [e-pub]. (https://doi.org/10.1056/NEJMoa2208687)

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