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
PROGNOSTICATION:
They also recommended some general guidelines which include,
- “In patients who are comatose after resuscitation from cardiac arrest, neurological prognostication should be performed using clinical examination, electrophysiology, biomarkers and imaging, to both inform patient’s relatives and to help clinicians to target treatments based on the patient’s chances of achieving a neurologically meaningful recovery.
- No single predictor is 100% accurate. Therefore, a multimodal neuroprognostication strategy is recommended.
- When predicting poor neurological outcome, a high specificity and precision are desirable, to avoid falsely pessimistic predictions.
- The clinical neurological examination is central to prognostication. To avoid falsely pessimistic predictions, clinicians should avoid potential confounding from sedatives and other drugs that may confound the results of the tests.
- When patients are treated with TTM, daily clinical examination is advocated but final prognostic assessment should be undertaken only after rewarming.
- Clinicians must be aware of the risk of a self-fulfilling prophecy bias, occurring when the results of an index test predicting poor outcome is used for treatment decisions, especially regarding life-sustaining therapies.
- Index tests for neurological prognostication are aimed at assessing the severity of hypoxic–ischaemic brain injury. The neurological prognosis is one of several aspects to consider in discussions around an individual’s potential for recovery.”
With regard to Multimodal prognostication, they recommend,
- “Start the prognostication assessment with an accurate clinical examination, to be performed only after major confounders (e.g. residual sedation, hypothermia) have been excluded.
- In a comatose patient with M ≤ 3 at ≥ 72 h from ROSC, in the absence of confounders, poor outcome is likely when two or more of the following predictors are present: no pupillary and corneal reflexes at ≥ 72 h, bilaterally absent N20 SSEP wave at ≥ 24 h, highly malignant EEG at > 24 h, neuron-specific enolase (NSE) > 60 µg L−1 at 48 h and/or 72 h, status myoclonus ≤ 72 h, or a diffuse and extensive anoxic injury on brain CT/MRI. Most of these signs can be recorded before 72 h from ROSC; however, their results will be evaluated only at the time of clinical prognostic assessment.
- Clinical examination is prone to interference from sedatives, opioids or muscle relaxants.”
Regarding Clinical examination, they recommend,
- “A potential confounding from residual sedation should always be considered and excluded.
- A Glasgow Motor Score of ≤ 3 (abnormal flexion or worse in response to pain) at 72 h or later after ROSC may identify patients in whom neurological prognostication may be needed.
- In patients who remain comatose at 72 h or later after ROSC the following tests may predict a poor neurological outcome:
- The bilateral absence of the standard pupillary light reflex.
- Quantitative pupillometry
- The bilateral absence of corneal reflex
- The presence of myoclonus within 96 h and, in particular, status myoclonus within 72 h
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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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