State of the art lecture: 21st Century Post resuscitation management
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1 State of the art lecture: 21st Century Post resuscitation management ACCA Masterclass 2017 Prof Alain CARIOU Intensive Care Unit - Cochin Hospital (APHP) Paris Descartes University INSERM U970 - France
2 COI disclosure Bard (fees for conferences)
3 The challenge is not only before hospital arrival! SCA/yrs 60% CPR 15-20% ROSC Pre-hospital period and ICU admission 5-10% survivors 7% no or minor sequelae Post-resuscitation: Post-cardiac arrest shock Brain damages Long-term?
4 Trends in Short- and Long-Term Survival Among OHCA Patients Alive at Hospital Arrival Wong MKY et al. Circulation days 1-year
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7 ICU mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, hiche JD, Carli P, Mira JP, Nolan J, Cariou A. Intensive Care Med 2013 n=768 n=499 n=269
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9 Coronary occlusion Defibrillation Ischemiareperfusion Drug toxicity (epinephrine?) Post-CA myocardial dysfunction SIRS
10 Post-cardiac arrest shock Bougouin W & Cariou A. Curr Opinion Crit Care 2013 Diagnostic of PRMD Echocardiography Screening for ischemic cause Coronary angiography PCI Preload assessment Fluid loading Hemodynamic optimization Persistent hypoperfusion Refractory cardiogenic shock Inotropic + vasopressors Dobutamine / Norepinephrine LV percutaneous mechanical assistance IABP, minlv devices Persistent hypoperfusion despite conventional therapies Neurological prognosis assumed favorable? Mechanical heart assistance ECLS
11 27%
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14 Should We Perform an Immediate Coronary Angiogram in All Survivors of OHCA With No Obvious Extra-Cardiac Cause? Insights from the PROCAT registry No obvious extra-cardiac cause Immediate coronary angiogram N=435 ST-segment elevation N=134 Other ECG pattern N=301 At least one significant lesion N=128 (96%) At least one significant lesion N= 176 (58%) PCI attempted N=110 (82%) PCI attempted N=92 PCI successful N=99 (74%) PCI successful N=78 Dumas F, Cariou A, Spaulding C. Circulation Cardiovasc Interv 2010
15 Should We Perform an Immediate Coronary Angiogram in All Survivors of OHCA With No Obvious Extra-Cardiac Cause? Insights from the PROCAT registry Multivariate analysis of early predictors of survival in OHCA pts without obvious extra-cardiac etiology OR [95% Conf.Interval] p-value BLS to ROSC > 15 minutes 0.28 ( ) < Collapse to BLS > 5 minutes 0.32 ( ) <0.001 Diabete mellitus 0.42 ( ) Age > 59 yrs 0.45 ( ) Blood lactate 0.55 ( ) <0.001 ST segment elevation 1.09 ( ) Initial Arrest Rhythm: VT/VF 1.82 ( ) Successfull PCI 2.06 ( ) Worse prognosis Betterprognosis Dumas F, Cariou A, Spaulding C. Circulation Cardiovasc Interv 2010
16 1. Based on the available data, emergent cardiac catheterisation lab evaluation (and immediate PCI if required) should be performed in selected adult patients with ROSC after OHCA of suspected cardiac origin with ST segment elevation on ECG.
17 Paul A, 67y Hypertension, smoking Resuscitated 1 hour ago from an OHCA: No flow: 4 minutes Low flow: 12 minutes VF (3 DC shocks) 2 mg epinephrine ECG post ROSC :
18 Should We Perform an Immediate Coronary Angiogram in All Survivors of OHCA With No Obvious Extra-Cardiac Cause? Insights from the PROCAT registry No obvious extra-cardiac cause Immediate coronary angiogram N=435 ST-segment elevation N=134 Other ECG pattern N=301 At least one significant lesion N=128 (96%) At least one significant lesion N= 176 (58%) PCI attempted N=110 (82%) PCI attempted N=92 (31%) PCI successful N=99 (74%) PCI successful N=78 (26%) Dumas F, Cariou A, Spaulding C. Circulation Cardiovasc Interv 2010
19 Is emergent PCI associated with a clinical benefit in post-cardiac arrest patients without ST segment elevation pattern? Insights from the Parisian registry (PROCAT II) Dumas F, Bougouin W, Geri G, Lamhaut L, Rosencher J, Pène F, Chiche JD, Varenne O, Carli P, Jouven X, Proportion of early PCI performed in NSTEMI population Mira JP, Spaulding C, Cariou A (JACC Cardiovasc Interv 2016) 60% 50% 40% 30% 20% 10% 0% 53% PROCAT 2 33% 33% 29% 25% 24% 21%
20 Is delayed PCI equivalent to immediate PCI after CA? Radsel P, Noc M. Resuscitation 84 (2013)
21 Is early PCI associated with a clinical benefit in post-cardiac arrest patients without STEMI pattern? Insights from the Parisian registry (PROCAT II) Multivariate analysis of predictors for good outcome in OHCA pts without obvious extra-cardiac etiology Odds Ratio [95% Conf. interval] p-value Age (year) 0.97 [ ] Male gender 1.20 [ ] 0.53 Diabetes 1.64 [ ] 0.11 Hypertension 1.04 [ ] 0.87 Smoking 1.18 [ ] 0.50 Public location 1.25 [ ] 0.37 Witnessed CA 3.21 [ ] 0.10 Bystander CPR 1.37 [ ] 0.19 Initial shockable rhythm 3.38 [ ] <0.001 Resuscitation lenghth < 20 min 3.13 [ ] <0.001 Epinephrine < 2 mg during CPR 0.27 [ ] <0.001 Targeted Temperature Management 0.93 [ ] 0.85 Post cardiac arrest shock 0.57 [ ] 0.02 PCI 1.86 [ ] Dumas F Cariou A. JACC Cardiovasc Interv 2016
22 Survival in patients without acute ST-elevation after CA and association to early coronary angiography - a post hoc analysis from the TTM trial Dankiewicz J et al. Intensive Care Med 2015 NS
23 DISCO Study
24 1. Based on the available data, emergent cardiac catheterisation lab evaluation (and immediate PCI if required) should be performed in selected adult patients with ROSC after OHCA of suspected cardiac origin with ST segment elevation on ECG. 2. In other patients, it is reasonable to discuss an emergent cardiac catheterisation lab evaluation after ROSC in patients with the highest risk of coronary cause of CA.
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26 Post-resuscitation disease after cardiac arrest: a sepsis-like syndrome? Adrie C, Laurent I, Monchi M, Cariou A, Dhainaut JF, Spaulding C. Current Opinion in Crit Care Ischemia and reperfusion syndrome 2. Inflammatory response 3. Coagulopathy 4. Circulatory failure 5. Adrenal dysfunction
27 Endotoxemia is correlated with gut injury after cardiac arrest and contributes to post-resuscitation shock Grimaldi D et al. Resuscitation 2012
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29 ICU mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, Chiche JD, Carli P, Mira JP, Nolan J, Cariou A Intensive Care Med % 80% 167 (41) 163 (46) 169 (43) 60% Deaths to neurological injury Deaths related to post cardiac arrest shock (25) 81 (22) Survivors 40% (23) Need for neuroprotective treatments 20% 137 (34) 113 (31) 134 (34) 0%
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32 Targeted temperature management after cardiac arrest WHAT LEVEL? 33 C: the dogma
33 Targeted temperature management after cardiac arrest WHAT LEVEL? 36 C: the future? 33 C: the dogma
34 Nielsen N. NEJM 2013 Nielsen N et al. NEJM 2013
35 Nielsen N. NEJM 2013 Nielsen N et al. NEJM 2013
36 2015 Guidelines: Temperature management after cardiac arrest? ILCOR and ERC/ESICM: Cooling is recommended +++ Target temperature between C
37 Predicting neurological outcome
38 Neuroprognostication after cardiac arrest Important: To inform patient s relatives To avoid futile treatments in patients with no chance of recovery High specificity and precision essential Lowest possible false positive rate (FPR) with narrow CIs
39 Total 87 studies 5231 patients
40 SSEP Cardiac arrest Days 1-2 Controlled temperature Rewarming Exclude confounders, particularly residual sedation Unconscious patient, M=1-2 at 72h after ROSC Days 3-5 One or both of the following: -No pupillary and corneal reflexes -Bilaterally absent N20 SSEP wave No Prognostication Yes Poor outcome very likely (FPR <5%, narrow 95%CIs) Sandroni C et al. Intensive Care Med 2014 Nolan JP et al. Intensive Care Med 2015
41 Magnetic Resonance Imaging (MRI) EEG - NSE SSEP CT Status Myoclonus Cardiac arrest Days 1-2 Controlled temperature Rewarming Exclude confounders, particularly residual sedation Unconscious patient, M=1-2 at 72h after ROSC Days 3-5 One or both of the following: -No pupillary and corneal reflexes -Bilaterally absent N20 SSEP wave No Prognostication Wait at least 24h Yes Poor outcome very likely (FPR <5%, narrow 95%CIs) Two or more of the following: -Status myoclonus 48h after ROSC -High NSE levels -Unreactive burst-suppression or status epilepticus on EEG -Diffuse anoxic injury on brain CT/MRI Yes Poor outcome likely No Indeterminate outcome Observe and re-evaluate Use multimodal prognostication whenever possible Sandroni C et al. Intensive Care Med 2014 Nolan JP et al. Intensive Care Med 2015
42 2015 ERC-ESICM Guidelines for management of post-cardiac arrest patients Nolan JP et al. ERC-ESICM guidelines. Resuscitation 2015 Nolan JP et al. ERC-ESICM guidelines. Intensive Care Med 2015
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