Post-resuscitation care for adults. Jerry Nolan Royal United Hospital Bath
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1 Post-resuscitation care for adults Jerry Nolan Royal United Hospital Bath
2 Post-resuscitation care for adults Titration of inspired oxygen concentration after ROSC Urgent coronary catheterisation and percutaneous coronary intervention (PCI) Targeted temperature management Prognostication Regionalisation of post-cardiac arrest care
3 Intensive Care Med 2015 online Resuscitation 2015;95:
4 Post-resuscitation Care (ROSC and comatose)
5 Post-resuscitation Care (ROSC and comatose) Airway and Breathing Maintain SpO % Advanced airway Waveform capnography Ventilate lungs to normocapnia Immediate treatment Circulation 12-lead ECG Obtain reliable intravenous access Aim for SBP > 100 mmhg Fluid (crystalloid) restore normovolaemia Intra-arterial blood pressure monitoring Consider vasopressor/ inotrope to maintain SBP Control temperature Constant temperature 32 o C 36 o C Sedation; control shivering
6 Optimal oxygenation during and after CPR Neumar RW Curr Opin Crit Care 2011;17:236-40
7 Oxygen therapy after ROSC As soon as arterial blood oxygen saturation can be monitored reliably (by blood gas analysis and/or pulse oximetry), titrate the inspired oxygen concentration to maintain the arterial blood oxygen saturation in the range of 94 98%. Avoid hypoxaemia ensure reliable measurement of arterial oxygen saturation before reducing the inspired oxygen concentration.
8 Post-resuscitation Care (ROSC and comatose) Likely cardiac cause? No Yes ST elevation on 12 lead ECG? Diagnosis No Consider Coronary angiography ± PCI Yes Coronary angiography ± PCI Consider CT brain and/or CTPA No Cause for cardiac arrest identified? Yes Treat non-cardiac cause of cardiac arrest Admit to Intensive Care Unit
9 Post-resuscitation Care (ROSC and comatose) Optimising recovery ICU management Temperature control: constant temperature 32 o C 36 o C for 24 h; prevent fever for at least 72 h Maintain normoxia and normocapnia; protective ventilation Optimise haemodynamics (MAP, lactate, ScvO 2, CO/CI, urine output) Echocardiography Maintain normoglycaemia Diagnose/treat seizures (EEG, sedation, anticonvulsants) Delay prognostication for at least 72 h Secondary prevention e.g. ICD, screen for inherited disorders, risk factor management Follow-up and rehabilitation
10 Targeted temperature management following cardiac arrest Maintain a constant, target temperature between 32 C and 36 C for those patients in whom temperature control is used. TTM is recommended for adults after OHCA with an initial shockable rhythm who remain unresponsive after ROSC. TTM is suggested for adults after OHCA with an initial non-shockable rhythm who remain unresponsive after ROSC. Donnino M. Resuscitation In press
11 Targeted temperature management following cardiac arrest TTM is suggested for adults after IHCA with any initial rhythm who remain unresponsive after ROSC. If targeted temperature management is used, it is suggested that the duration is at least 24 h. Donnino M. Resuscitation In press
12 Targeted temperature management following cardiac arrest Following the TTM trial, 36 o C is becoming the preferred target temperature for post-cardiac arrest temperature control. The advantages compared with 33 o C include: Reduced need for vasopressor support. Lactate values are lower. Rewarming phase is shorter. Reduced risk of rebound hyperthermia after rewarming.
13 Resuscitation 2014;85:
14 Prognostication Prognostication is generally delayed until at least 72 h after return of spontaneous circulation and multiple modes are used. These include: Clinical examination Electrophysiology Biomarkers Imaging
15 Taccone FS. Crit Care 2014;18:202
16 Cardiac arrest Prognostication for Comatose Survivors of Cardiac Arrest Days 1-2 CT EEG - NSE Status Myoclonus SSEP Controlled temperature Rewarming Exclude confounders, particularly residual sedation Unconscious patient, M=1-2 at 72 h after ROSC Days 3-5 Magnetic Resonance Imaging (MRI) One or both of the following: No pupillary and corneal reflexes Bilaterally absent N20 SSEP wave (1) No Yes Wait at least 24 h Poor outcome very likely (FPR < 5 %, narrow 95 % CIs) Two or more of the following: Status myoclonus 48 h after ROSC High NSE levels (2) Unreactive burst-suppression or status epilepticus on EEG Diffuse anoxic injury on brain CT/MRI (2) No Yes Indeterminate outcome Observe and re-evaluate Poor outcome likely Use multimodal prognostication whenever possible
17 Prognostication for Comatose Survivors of Cardiac Arrest Cardiac arrest Days 1-2 CT Status Myoclonus Controlled temperature Rewarming EEG - NSE SSEP Exclude confounders, particularly residual sedation Unconscious patient, M=1-2 at 72 h after ROSC
18 EEG - NSE SSEP Exclude confounders, particularly residual sedation Unconscious patient, M=1-2 at 72 h after ROSC Days 3-5 Magnetic Resonance Imaging (MRI) One or both of the following: No pupillary and corneal reflexes Bilaterally absent N20 SSEP wave (1) No Yes Wait at least 24 h Poor outcome very likely (FPR < 5 %, narrow 95 % CIs) Two or more of the following: Status myoclonus 48 h after ROSC High NSE levels (2) Unreactive burst-suppression or status epilepticus on EEG Diffuse anoxic injury on brain CT/MRI (2) No Yes Indeterminate outcome Observe and re-evaluate Poor outcome likely
19 Cardiac arrest centres Logical progression of existing regionalisation 24/7 access to cardiac cath lab Comprehensive post-resuscitation care Neurological support for prognostication SSEPs, NSE, continuous EEG? Indirect evidence for better outcomes
20 Post-resuscitation care for adults New ERC-ESICM Guidelines New section for RC (UK) Guidelines Urgent coronary catheterisation Temperature control Prognostication Cardiac arrest centres
21 Sept 2010 patients with ROSC conveyed directly to one of 8 Heart Attack Centres Utstein = witnessed VF
22 Cardiac arrest Days 1-2 CT Status Myoclonus Controlled temperature Rewarming EEG - NSE SSEP Exclude confounders, particularly residual sedation Unconscious patient, M=1-2 at 72h after ROSC Days 3-5 Magnetic Resonance Imaging (MRI) One or both of the following: - No pupillary and corneal reflexes - Bilaterally absent N20 SSEP wave ( 1 ) Two or more of the following: - Status myoclonus 48h after ROSC - High NSE levels ( 2 ) - Unreactive burst-suppression or status epilepticus on EEG - Diffuse anoxic injury on brain CT/MRI ( 2 ) No Wait at least 24h No Indeterminate outcome Observe and re-evaluate Use multimodal prognostication whenever possible Yes Yes Poor outcome very likely (FPR <5%, narrow 95%CIs) Poor outcome likely (1) At 24h after ROSC in patients not treated with targeted temperature (2) See text for details. Sandroni 2014
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