Post-resuscitation care: ERC/ESICM updated Guidelines
Concerning Neurophysiology, they recommend,
- “Perform an EEG in patients who are unconscious after the arrest.
- Highly malignant EEG-patterns include suppressed background with or without periodic discharges and burst-suppression. We suggest using these EEG-patterns after the end of TTM and after sedation has been cleared as indicators of a poor prognosis.
- The presence of unequivocal seizures on EEG during the first 72 h after ROSC is an indicator of a poor prognosis.
- Absence of background reactivity on EEG is an indicator of poor prognosis after cardiac arrest.
- Bilateral absence of somatosensory evoked cortical N20-potentials is an indicator of poor prognosis after cardiac arrest.
- Always consider the results of EEG and somatosensory evoked potentials (SSEP) in the context of clinical examination findings and other tests. Always consider using a neuromuscular blocking drug when performing SSEP.”
For Biomarkers, they recommend, “Use serial measurements of NSE in combination with other methods to predict outcome after cardiac arrest. Increasing values between 24 and 48 h or 72 h in combination with high values at 48 and 72 h indicates a poor prognosis”.
Regarding Imaging, they recommend to,
- “Use brain imaging studies for predicting poor neurological outcome after cardiac arrest in combination with other predictors, in centres where specific experience in these studies is available.
- Use presence of generalised brain oedema, manifested by a marked reduction of the grey matter/white matter ratio on brain CT, or extensive diffusion restriction on brain MRI to predict poor neurological outcome after cardiac arrest.
- Always consider findings from imaging in combination with other methods for neurological prognostication.”
With regard to WITHDRAWAL OF LIFE-SUSTAINING THERAPY, they recommend,
- “Separate discussions around withdrawal of life-sustaining therapy (WLST) and the assessment of prognosis for neurological recovery; WLST decisions should consider aspects other than brain injury such as age, co-morbidity, general organ function and the patients’ preferences.
Allocate sufficient time for communication around the level-of-treatment decision within the team and with the relatives.”
- Organise follow-up for all cardiac arrest survivors within 3 months after hospital discharge, including the following:
1. Screening for cognitive problems.
2.Screening for emotional problems and fatigue.
3.Providing information and support for survivors and family members.”
For ORGAN DONATION, they recommend,
“All decisions concerning organ donation must follow local legal and ethical requirements.
Organ donation should be considered in those who have achieved ROSC and who fulfil neurological criteria for death.
In comatose ventilated patients who do not fulfil neurological criteria for death, if a decision to start end-of-life care and withdrawal of life support is made, organ donation should be considered for when circulatory arrest occurs.”
Concerning, CARDIAC ARREST CENTERS, they recommend, “Adult patients with non-traumatic OHCA should be considered for transport to a cardiac arrest centre according to local protocol.”
For further information:
https://link.springer.com/article/10.1007/s00134-021-06368-4
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.
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."
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