Post-resuscitation care: ERC/ESICM updated Guidelines
Written By : Dr Kartikeya Kohli
Medically Reviewed By : Dr. Kamal Kant Kohli
Published On 2021-03-28 13:27 GMT | Update On 2021-03-28 13:27 GMT
CIRCULATION:
With regard to Coronary reperfusion, they recommend
- “Emergent cardiac catheterisation laboratory evaluation (and immediate PCI if required) should be performed in adult patients with ROSC after cardiac arrest of suspected cardiac origin with ST-elevation on the ECG.
- In patients with ROSC after out-of-hospital cardiac arrest (OHCA) without ST-elevation on the ECG, emergent cardiac catheterisation laboratory evaluation should be considered if there is an estimated high probability of acute coronary occlusion (e.g. patients with haemodynamic and/or electrical instability).”
For Haemodynamic monitoring and management, they recommend,
- “All patients should be monitored with an arterial line for continuous blood pressure measurements, and it is reasonable to monitor cardiac output in haemodynamically unstable patients.
- Perform early (as soon as possible) echocardiography in all patients to detect any underlying cardiac pathology and quantify the degree of myocardial dysfunction.
- Avoid hypotension (< 65 mmHg). Target mean arterial pressure (MAP) to achieve adequate urine output (> 0.5 mL kg−1 h−1) and normal or decreasing lactate.
- During TTM at 33 °C, bradycardia may be left untreated if blood pressure, lactate, ScvO2 or SvO2 is adequate. If not, consider increasing the target temperature, but to no higher than 36 °C.
- Maintain perfusion with fluids, noradrenaline and/or dobutamine, depending on individual patient need for intravascular volume, vasoconstriction or inotropy.
- Do not give steroids routinely after cardiac arrest.
- Avoid hypokalaemia, which is associated with ventricular arrhythmias.
- Consider mechanical circulatory support (such as intra-aortic balloon pump, left-ventricular assist device or arterio-venous extra corporal membrane oxygenation) for persisting cardiogenic shock from left ventricular failure if treatment with fluid resuscitation, inotropes and vasoactive drugs is insufficient. Left-ventricular assist devices or arterio-venous extra corporal membrane oxygenation should also be considered in haemodynamically unstable patients with acute coronary syndromes (ACS) and recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) despite optimal therapy.”
DISABILITY:
Concerning Control of seizures, they recommend,
- “We recommend using electroencephalography (EEG) to diagnose electrographic seizures in patients with clinical convulsions and to monitor treatment effects.
- To treat seizures after cardiac arrest, we suggest levetiracetam or sodium valproate as first-line antiepileptic drugs in addition to sedative drugs.
- We suggest that routine seizure prophylaxis is not used in post-cardiac arrest patients.”
With regard to Temperature control, they recommend,
- “We recommend targeted temperature management (TTM) for adults after either OHCA or in-hospital cardiac arrest (IHCA) (with any initial rhythm) who remain unresponsive after ROSC.
- Maintain a target temperature at a constant value between 32 and 36 °C for at least 24 h.
- Avoid fever (> 37.7 °C) for at least 72 h after ROSC in patients who remain in coma.
- Do not use pre-hospital intravenous cold fluids to initiate hypothermia.”
For General intensive care management, they recommend to,
- “Use short acting sedatives and opioids.
- Avoid using a neuromuscular blocking drug routinely in patients undergoing TTM, but it may be considered in case of severe shivering during TTM.
- Provide stress ulcer prophylaxis routinely in cardiac arrest patients.
- Provide deep venous thrombosis prophylaxis.
- Target a blood glucose of 7.8–10 mmol L−1 (140–180 mg dL−1) using an infusion of insulin if required; avoid hypoglycaemia (< 4.0 mmol L−1 (< 70 mg dL−1)
- Start enteral feeding at low rates (trophic feeding) during TTM and increase after rewarming if indicated. If TTM of 36 °C is used as the target temperature, gastric feeding rates may be increased early during TTM.
- We do not recommend using prophylactic antibiotics routinely.”
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In 2015 the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) collaborated to produce their first combined post-resuscitation care guidelines. Recently they have updated their these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The updated guidelines were published in the journal Intensive Care Medicine on March 25, 2021.
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.
Courtesy Jerry.P Nolan et al. Intensive Care Medicine
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:
With regard to Airway management after return of spontaneous circulation, they recommend,
- "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."
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