Post-resuscitation care: ERC/ESICM updated Guidelines

• “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).”

• “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.”