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Michael Parr speaks at Bedside Critical Care Conference 4 about how to best manage post cardiac arrest patients in the ICU. The audio for this great talk can be found at www.intensivecarenetwork.com
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Post cardiac arrest ICU care
1. Patients resuscitated after prolonged cardiac arrest will develop post cardiac arrest syndrome
2. Out-of-hospital cardiac arrest survivors should be considered for urgent PCI unless the cause of cardiac arrest was clearly non-cardiac or continued treatment is considered futile.
3. Interventions may impact on neurological outcome: especially targeted temperature management.
4. Comatose survivors: prediction of the final outcome in the first few days may be unreliable.
Post-cardiac arrest syndrome
• Post-cardiac arrest brain injury – coma and seizures. • Post-cardiac-arrest myocardial dysfunction – can be
severe and usually recovers after 48-72 hours.
Post-cardiac arrest syndrome
• Post-cardiac arrest brain injury – coma and seizures. • Post-cardiac-arrest myocardial dysfunction – can be
severe and usually recovers after 48-72 hours.• Systemic ischaemia/reperfusion response –
reperfusion can cause apoptosis effecting all organ systems.
Post-cardiac arrest syndrome
• Post-cardiac arrest brain injury – coma and seizures. • Post-cardiac-arrest myocardial dysfunction – can be
severe and usually recovers after 48-72 hours.• Systemic ischaemia/reperfusion response –
reperfusion can cause apoptosis effecting all organ systems.
• Persisting precipitating pathology – coronary artery disease is the commonest precipitating cause after OHCA.
Early coronary reperfusion
714 OHCA admitted to ICU 714 OHCA admitted to ICU
No obvious extra-cardiac cause
(n = 435)
No obvious extra-cardiac cause
(n = 435)
STEMIN = 134 (31%)
STEMIN = 134 (31%)
≥ coronary lesionN = 128 (96%)
≥ coronary lesionN = 128 (96%)
Successful PCIN = 99 (74%)
Successful PCIN = 99 (74%)
Other ECGN = 301 (69%)
Other ECGN = 301 (69%)
≥ coronary lesionN = 176 (58%)
≥ coronary lesionN = 176 (58%)
Successful PCIN = 78 (26%)
Successful PCIN = 78 (26%)
Dumas F. Circ Cardiovasc Interv
2010;3:200-7
PROCATParisian Region Out of hospital Cardiac ArresT
Registry
Successful angioplasty independent predictor survival OR 2.06 (1.16 to 3.66)
ECG criteria for selection of AMI in OHCA patients (n = 165)
Sensitivity (%) (CI)
Specificity (%) (CI)
ST-elevation (n = 70) 88 (77 – 95) 84 (75 – 90)
ST-elevation and/or depression (n = 96) 95 (86 – 99) 62 (52 – 72)
As above + LBBB or nonspecific QRS complexes (n = 116)
100 (94 – 100) 46 (36 – 56)
Resuscitation 2011;82:1148-53
Angiographic AMI in 60 (36%) patients
PCI after cardiac arrestST elevation vs. no ST elevation
Radsel P. Am J Cardiol 2011;108:634-8
Dumas F. Circ Cardiovasc Interv 2010;3:200-7
Cronier P. Crit Care 2011;15:R122-9
Mooney MR. Circulation 2011;124:206-14
%
Kern KB. J Am Coll Cardiol Intv 2012;5:597-605 Kern KB. J Am Coll Cardiol Intv 2012;5:597-605
Mechanisms of ischemia/reperfusion injury.
Levitsky S Circulation 2006;114:I-339-I-343
Copyright © American Heart Association
Pacing
Cooling
IABP
Defibrillator
Inotropes
Ventilation
Enteral nutrition
Insulin
Mode of death after admission to ITU following cardiac arrest
126 (62%) deaths out of 206 admissions
Laver S. Intensive Care Med 2004; 30:2126-8Laver S. Intensive Care Med 2004; 30:2126-8
Improving neurological outcome after cardiac arrest
• Controlled re-oxygenation• Cerebral perfusion• Glucose control• Control of seizures• Targeted temperature
management
Airway and breathing with controlled re-oxygenation
In-hospital mortality n (%) [95% CI]*
*P<0.001 hyperoxia vs. normoxia andhyperoxia vs. hypoxia
Circulation 2011;123:2717-2722
Intensive care registry studies
• High FiO2 surrogate marker of illness severity
• First 60 min post ROSC data is missed• Duration and timing of hyperoxia unknown• Impact of therapeutic hypothermia?• Need large prehospital RCT
Targeted oxygen therapy after return of spontaneous circulation
• “…as soon as arterial blood oxygen saturation can be monitored reliably… titrate the FiO2 to maintain the arterial blood oxygen saturation in the range of 94 -98%.”
Target Temperature Management After Cardiac Arrest (TTM) Trial
• RCT out-of-hospital cardiac arrest – all rhythms (n = 950)
• 33oC versus 36oC for 24 h• Neurological evaluation 72 h after rewarm• Primary outcome – mortality at 6 months• Finished recruiting• NCT01020916
Nielsen N. Am Heart J 2012;163:541-8
Target Temperature Management - the TTM trial
Clinicaltrials.gov: [email protected] embargoed-17th Nov to be presented at the AHA
Target Temperature Management after out-of-hospital cardiac arrest-arandomized, parallel-group, assessor-blinded clinical trial rationale and design.Am Heart J. 2012;163(4):541-8
Unconscious adult patients with spontaneous circulation after out of hospital cardiac arrest should be cooled to 32-34oC for 12-24 hours when the initial rhythm was VF
For any other rhythm, or cardiac arrest in hospital, such cooling may also be beneficial
Therapeutic hypothermia after cardiac arrest
An Advisory Statement by the ALS Task Force of the International Liaison Committee on Resuscitation (ILCOR)
A
B
Knowledge gapsWhat rhythms?
When to start cooling?What technique?
How long?
Cerebral resuscitation• Sedation
– propofol, fentanyl– Clearance of many drugs is reduced by a third at 34oC
• Cerebral perfusion– Autoregulation is impaired after cardiac arrest– Aim to maintain a normal mean arterial pressure for that particular patient.
• Seizures or myoclonus or both occur in about 24% of those who remain comatose and cooled after cardiac arrest– Conazepam, sodium valproate, levetiracetam
• Blood glucose– 4-10 mmolL-1
Prognostication
Prognostication
• Therapeutic hypothermia invalidates previous “standards”
• May reflect a direct effect of hypothermia on
progress of neurological recovery and/or the residual effects of sedatives and opioids (larger doses: longer to clear)
SSEPs
Leithner C. Neurology 2010;74:965-936 patients with absent N20 – 2 good recoveries
When should neurological prognostication be carried out?
• Since induced hypothermia changes the conditions for the clinical neurological examination, there is good reason to postpone the final assessment of hypothermia treated patients to at least 72 h after normothermia, which corresponds to approximately 4.5 days after the arrest.
Prognostication
• Findings at the clinical neurological examination• Neurophysiological methods (EEG/SSEP)• Clinical and electrographic seizures• Diagnostic imaging (CT/MRI)• Biochemical markers• Recommended routine for prognostication
Early: During first 24 h or before onset of rewarming (24 h). Late: After the first 24 h or after rewarming has been initiated.
1: Good support in the literature and goodreliability. 2: Good support in the literature, but moderate reliability. 3: Some support in the literature and limited reliability.
Early: During first 24 h or before onset of rewarming (24 h). Late: After the first 24 h or after rewarming has been initiated.
1: Good support in the literature and goodreliability. 2: Good support in the literature, but moderate reliability. 3: Some support in the literature and limited reliability.
