Post-resuscitation care: ERC/ESICM updated Guidelines

They have made the recommendations in the following areas such as:

• Post-cardiac arrest syndrome,
• Diagnosis of cause of cardiac arrest,
• Control of oxygenation and ventilation,
• Coronary reperfusion,
• Haemodynamic monitoring and management,
• Control of seizures,
• Temperature control,
• General intensive care management,
• Prognostication,
• Long-term outcome,
• Rehabilitation and organ donation.

SUMMARY OF MAJOR RECOMMENDATION:

With regard to Immediate post-resuscitation care, the panel recommend,

"Post-resuscitation care is started immediately after sustained ROSC, regardless of location.

For out-of-hospital cardiac arrest consider transport to a cardiac arrest centre."

For Diagnosing the cause of cardiac arrest, they recommend,

• "If there is clinical (e.g. haemodynamic instability) or ECG evidence of myocardial ischaemia, undertake coronary angiography first. This is followed by CT brain and/or CT pulmonary angiography if coronary angiography fails to identify causative lesions.
• Early identification of a respiratory or neurological cause can be achieved by performing a brain and chest CT-scan at hospital admission, before or after coronary angiography (see coronary reperfusion).
• If there are signs or symptoms pre-arrest suggesting a neurological or respiratory cause (e.g. headache, seizures or neurological deficits, shortness of breath or documented hypoxaemia in patients with known respiratory disease), perform a CT brain and/or a CT pulmonary angiogram."

AIRWAY AND BREATHING:

• "Airway and ventilation support should continue after return of spontaneous circulation (ROSC) is achieved.
• Patients who have had a brief period of cardiac arrest and an immediate return of normal cerebral function and are breathing normally may not require tracheal intubation but should be given oxygen via a facemask if their arterial blood oxygen saturation is less than 94%.
• Patients who remain comatose following ROSC, or who have another clinical indication for sedation and mechanical ventilation, should have their trachea intubated if this has not been done already during CPR.
• Tracheal intubation should be performed only by experienced operators who have a high success rate.
• Correct placement of the tracheal tube must be confirmed with waveform capnography.
• In the absence of personnel experienced in tracheal intubation, it is reasonable to insert a supraglottic airway (SGA) or maintain the airway with basic techniques until skilled intubators are available."
• "After ROSC, use 100% (or maximum available) inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably.
• After ROSC, once SpO2 can be measured reliably or arterial blood gas values are obtained, titrate the inspired oxygen to achieve an arterial oxygen saturation of 94–98% or arterial partial pressure of oxygen (PaO2) of 10–13 kPa or 75–100 mmHg .
• Avoid hypoxaemia (PaO2 < 8 kPa or 60 mmHg) following ROSC.
• Avoid hyperoxaemia following ROSC."
• "Obtain an arterial blood gas and use end tidal CO2 in mechanically ventilated patients.
• In patients requiring mechanical ventilation after ROSC, adjust ventilation to target a normal arterial partial pressure of carbon dioxide (PaCO2), i.e. 4.5–6.0 kPa or 35–45 mmHg.
• In patients treated with targeted temperature management (TTM) monitor PaCO2 frequently as hypocapnia may occur.
• During TTM and lower temperatures use consistently either a temperature or non-temperature corrected approach for measuring blood gas values.
• Use a lung protective ventilation strategy aiming for a tidal volume of 6–8 mL kg−1 ideal body weight."

Concerning Control of oxygenation, they recommend,

• "After ROSC, use 100% (or maximum available) inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably.
• After ROSC, once SpO2 can be measured reliably or arterial blood gas values are obtained, titrate the inspired oxygen to achieve an arterial oxygen saturation of 94–98% or arterial partial pressure of oxygen (PaO2) of 10–13 kPa or 75–100 mmHg .
• Avoid hypoxaemia (PaO2 < 8 kPa or 60 mmHg) following ROSC.
• Avoid hyperoxaemia following ROSC."

With regard to Control of ventilation, they recommend,

• "Obtain an arterial blood gas and use end tidal CO2 in mechanically ventilated patients.
• In patients requiring mechanical ventilation after ROSC, adjust ventilation to target a normal arterial partial pressure of carbon dioxide (PaCO2), i.e. 4.5–6.0 kPa or 35–45 mmHg.
• In patients treated with targeted temperature management (TTM) monitor PaCO2 frequently as hypocapnia may occur.
• During TTM and lower temperatures use consistently either a temperature or non-temperature corrected approach for measuring blood gas values.
• Use a lung protective ventilation strategy aiming for a tidal volume of 6–8 mL kg−1 ideal body weight."