Post Cardiac Arrest Care 2015 American Heart Association Guideline Update for CPR and Emergency Cardiovascular Care

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1 Post Cardiac Arrest Care 2015 American Heart Association Guideline Update for CPR and Emergency Cardiovascular Care รศ.ดร.พญ.ต นหยง พ พานเมฆาภรณ ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม

2 System of Care for Improving Post Cardiac Arrest Outcomes Post cardiac arrest care is a critical component of advanced life support Most death occur during the first 24 hours after cardiac arrest Because multiple organ are affected after cardiac arrest, successful post-cardiac arrest care will benefit from the development of system wide plan for pro-active treatment of these patients

3 System of care for improving post cardiac arrest outcomes The data suggest proactive titration of post cardiac arrest hemodynamics to levels intended to organ perfusion and oxygenation may improve outcome

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5 Summary of Key Issues and Major Changes Emergency coronary angiography is recommended for all patients with ST elevation and for hemodynamic or electrically unstable patients without ST elevation for whom a cardiovascular lesion is suspected TTM recommendation have been updated with new evidence suggest that a range of temperature may be acceptable to target in the post-cardiac arrest period

6 Summary of Key Issues and Major Changes After TTM is completed, fever may develop. While there are conflicting observation data about the harm of the fever after TTM, the prevention of fever is considered benign and therefore is considered to persue. Identification and correction of hypotension is recommended in the immediate post-cardiac arrest period

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11 Summary of Key Issues and Major Changes Prognostication is now recommended no sooner than 72 hours after the completion of TTM; for those who do not have TTM, prognostication is not recommended any sooner than 72 hours after ROSC. All patients who progress to brain death or circulatory death after cardiac arrest should be considered potential organ donors

12 Coronary Angiography 2015 (UPDATED) A 12 lead ECG should be obtained as soon as possible after ROSC to determine whether acute ST elevation is present (Class I, LOE B) Emergency coronary angiography (rather than later in hospital stay or not at all) Out of hospital cardiac arrest (OHCA) patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR)

13 Coronary angiography Select adult patients who are comatosed after OHCA of suspected cardiac origin but without ST elevation of ECG (Class IIa, LOE B-NR) Post cardiac arrest patients for whom coronary angiogram is indicated regardless patient is comatose or awake (Class IIa, LOE B-NR)

14 Coronary angiography 2010 Guideline Primary PCI after ROSC in subject with arrest of presumed ischemic cardiac etiology of arrest may be reasonable, even in the absence of clearly defined STEMI. Appropriate treatment of acute coronary syndrome or STEMI, including PCI or fibrinolysis, should be initiated regardless of coma

15 Why Positive association between emergency coronary revascularization and both survival and functional outcome The outcome of coma may be improved by correction of cardiac instability and the prognosis of coma cannot be reliably determined in the first few hours after cardiac arrest

16 Target Temperature Management (TTM) Comatose (ie, lack of meaningful response to verbal commands) adults patients with ROSC after cardiac arrest have TTM VF/pulseless VT OHCA (Class I, LOE- R) Non VF, pulseless VT (nonshockable) and inhospital cardiac arrest (Class I,LOE C-EO)

17 Target Temperature Management (TTM) 2015 (updated) All comatose adult patients (ie, lacking meaningful responses to verbal commands) with ROSC should have TTM, with a target temperature between 32 and 36 C selected and achieved, then maintained constantly for at least 24 hours (Class I, LOE B-R) Follow by a gradual return (approximately 0.25 C / hour ) return to normothermia

18 Target Temperature Management (TTM) 2010 Guideline Comatose adult patients with ROSC after out of hospital VF cardiac arrest should be cooled to 32 C to 34 C for 12 to 24 hours. Induced hypothermia also may be considered for comatose adult patients with ROSC after IHCA of any initial rhythm of PEA or asystole

19 Target Temperature Management (TTM) Why A recent high quality study compared temperature management at 36 C and 32 C and found outcomes to be similar for both Clinician can select from wider range of target temperatures The selected temperature may be determined by clinician preference or clinical factors

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22 Hypothermia in prehospital setting Five randomized controlled trials compared post ROSC use of cold intravenous fluid to no cooling and intra-arrest intranasal cooling to no cooling When cooling maneuvers were initiated in the prehospital setting - No different in survival or neurological recovery

23 Hypothermia in prehospital setting Patients treated with prehospital infusion of 2 L of cold fluids Pulmonary edema and rearrest - Pulmonary edema and rearrest

24 Out- of- hospital cooling The routine prehospital cooling of patients with rapid infusion of cold IV fluid after ROSC is not recommended. Against the routine prehospital cooling after ROSC with rapid infusion of cold IV fluid (Class III, No benefit, LOE A).

25 Out- of- hospital cooling Why No benefit to prehospital cooling and also identified potential complications when using cold IV fluids for prehospital cooling Whether different method or devices for temperature control outside of the hospital are beneficial is unknown

26 Continuing Temperature management 2015 (updated) over 24 hours Actively preventing fever in comatose patients after TTM is reasonable Why Fever after rewarming from TTM is associated with worsened neurological injury Preventing fever after TTM is relatively benign and fever may be associated with harm

27 Hemodynamic goals after resuscitation 2015 (updated) Avoid and immediately correcting hypotension (SBP < 90 mmhg or MAP < 65 mmhg) during postresuscitation care may be reasonable. (Class IIb, LOE C-LD) The systematic reviews did not identify specific targets for other variables and individual goals likely based on patient-specific co-morbidities and underlying physiology

28 Hemodynamic goals after resuscitation Why SBP < 90 mmhg or MAP < 65 mmhg is associated with higher mortality and diminished functional recovery, while SBP > 100 mmhg are associated with better recovery

29 Common vasoactive drugs Drugs Epinephrine Norepinephrine Typical starting dose mcg/kg/min Useful for symptomatic bradycardia if atropine and transcutaneous pacing fail Used to treat severe hypotension (SBP < 70mmHg) Useful for anaphylaxis associated with hemodynamic instability mcg/kg/min Used to treat severe hypotension or a low total peripheral vascular resistance Relatively contraindicated in patients with hypovolemia Usually induces renal or mesenteric vasoconstriction

30 Phenylephrine Dopamine Dobutamine mcg/kg/min Used to treat severe hypotension or a low total peripheral vascular resistance 5-10 mcg/kg/min Used to treat hypotension, especially if it is associated with symptomatic bradycardia Maintain renal blood flow and improved renal function (low dose) 5-10 mcg/kg/min The vasodilating β2 agrenergic receptor counterbalance the vasoconstricting α adrenergic effect Milrinone Load 50 mcg/kg over 10 minutes then mcg/kg/min Use to treat cardiac output May cause less tachycardia than dobutamine

31 Prognostication after cardiac arrest 2015 (Updated) The earliest time for prognostication using clinical examination in patients treated with TTM, where sedation or paralysis could be confounder, may be 72 hours after return to normothermia (Class IIb, LOE C-EO) The earliest time to prognosticate a poor neurological outcome using clinical examination in patients not treated with TTM is 72 hours after cardiac arrest (Class I, LOE B-NR)

32 Prognostication after cardiac arrest This time until prognostication can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination (Class IIa, LOE C-LD)

33 Prognostication after cardiac arrest 2010 Guideline While times for usefulness of specific tests were identified, no specific overall recommendation was made about time to prognostication

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35 Organ donation 2015 (updated) All patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death should be evaluated as potential organ donors Patients who do not achieve ROSC and would otherwise have resuscitation terminated may be considered as potential kidney or liver donors in setting where rapid organ recovery programs exist

36 Organ donation 2010 Guideline Adults patients who progress to brain death after resuscitation from cardiac arrest should be considered for organ donation

37 Organ donation Why There had been no difference reported in immediate or long-term function of organ from donors who reach brain death from other causes Organ transplanted from these donors have success rates comparable to organs recovered from similar donors with other conditions

38 Multiple System Approach to Post Cardiac Arrest Care Ventilation Capnography Chest x-ray Pulse oximetry / arterial blood gas Mechanical ventilation Hemodynamics Frequently blood pressure monitoring /arterial line Treat hypotension Cardiovascular Continuous cardiac monitoring 12 lead ECG/ troponin Treat acute coronary syndrome Echocardiogram Treat myocardial stunning

39 Multiple System Approach to Post Cardiac Arrest Care Neurological Serial neurological exam EEG monitoring if comatose TTM if comatose Non enhanced CT scan Sedation and paralysis Metabolic Serum lactate Serum potassium Urine output/ serum creatinine Serum glucose Avoid hypotonic fluid

40 Pediatric Post Cardiac Arrest Care

41 Post Cardiac Arrest Temperature 2015 (updated) For infant and children remaining comatose after OHCA, it is reasonable to maintain 5 days of continuous normothermia (36 to 37.5 C) or to maintain 2 days of initial continuous hypothermia (32 to 34 C) followed by 3 days of continuous normothermia (Class IIa, LOE B-R) Continuous measurement of temperature during this time period is recommended (Class I, LOE B-NR)

42 Post Cardiac Arrest Temperature For infant and children remaining comatose after IHCA, there is insufficient evidence to recommend cooling over normothermia Fever (temperature 38 C or higher) should be aggressively treated after ROSC (Class I, LOE B-NR)

43 Post Cardiac Arrest Oxygenation It may be reasonable for rescuers to target normoxemia after ROSC (Class IIb, LOE-NR)

44 Post Cardiac Arrest PaCO2 It is reasonable for practioners to a target PaCO2 after ROSC that is appropriate to specific patient condition, and limit exposure to severe hypercapnia and hypocania (Class II, LOE C-LD) Monitored exhaled CO2, especially transport and diagnostic procedures (Class IIb, LOE B)

45 Post Cardiac Fluids and Inotropes After ROSC, parenteral fluid and/ or inotropes or vasoactive drugs be used to maintain SBP greater than fifths percentile of age (Class I, LOE LD) Continuous arterial pressure monitoring is recommended to identify and treat hypotension ((Class I, LOE EO)

46 Postresuscitation Use of EEG for Prognosis EEGs performed within the first 7 days after pediatric cardiac arrest may be considered in prognosticating neurological outcome at the time of hospital discharge (Class IIb, LOE C-LD) but should not used as the sole criterion

47 Predictive factors after cardiac arrest Several post ROSC factors have been studied as possible predictors of survival and neurological outcome after pediatric cardiac arrest These include pupillary responses, the presence of hypotension, serum neurological biomarkers, and serum lactate

48 Predictive factors after cardiac arrest The reliability of any 1 variable for prognostication in children after cardiac arrest has not been established Practitioners should consider multiple factors when predicting outcomes in infants and children who achieve ROSC after cardiac arrest (Class I, LOE C-LD)

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50 Thank you for your attention

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