Research paperPost resuscitation management of cardiac arrest patients in the critical care environment: A retrospective audit of compliance with evidence based guidelines
Introduction
There is a clear relationship between evidence-based post resuscitation care and survival to, and functional status at hospital discharge.1, 2 Further, it is clear that resuscitation should not stop after Return of Spontaneous Circulation and that post resuscitation care should be considered part of the resuscitation process.2 Post cardiac arrest syndrome is a unique and complex combination of the following pathophysiological processes: (1) brain injury, (2) myocardial dysfunction, (3) systemic response to reperfusion and (4) residual issues related to the cause of cardiac arrest.3 There is a growing body of evidence that shows that post cardiac arrest syndrome has a significant impact on mortality and morbidity.4 Protocols for the standardised management of patients following resuscitation including: targeted temperature management (TTM), previously known as therapeutic hypothermia, glycaemic control, controlled ventilation and oxygenation, controlled haemodynamic support, prognostication consideration and timeliness of interventions have been found to improve patient outcomes: a summary is provided in Table 1.1, 5, 6 However, there are a number of barriers to implementation of optimal post resuscitation care in practice including high resource requirements and coordination of care between multiple providers.4 For the purpose of this paper, post resuscitation care refers to the care provided following Return of Spontaneous Circulation.
At the time of the study, the Australian Resuscitation Council18, 19 recommended the following key elements of post resuscitation care:
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Systolic blood pressure (SBP) greater than 100 mmHg with the administration of vasopressors and or intravenous fluids if required.
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Intubation and ventilation guided by appropriate monitoring to maintain an oxygen saturation of 94–98% and normocarbia.
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Blood glucose level: frequent monitoring of blood glucose level (BGL) and treatment of hyperglycaemia greater than 10 mmol/L and avoiding hypoglycaemia.
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Administration of antiarrhythmic medications if required.
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Induction of therapeutic hypothermia (now TTM) and following rewarming avoiding hyperthermia.
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Consideration of use of anticonvulsant medications.
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Immediate angiography and/or early Percutaneous Coronary Intervention (PCI) in patients with ST Elevation Acute Myocardial Infarction (STEMI) or new Left Bundle Branch Block (LBBB) on Electrocardiograph (ECG) following Return of Spontaneous Circulation (ROSC).
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Management of resuscitation related injuries.
While there is a clear evidence base for post resuscitation care, the quality of delivery post resuscitation care in Australian hospitals is poorly understood. Studies of single approaches such as TTM and angiography have shown positive results,10 however, these studies fail to encompass the complexity of implementing multi-component interventions in practice. The International Liaison Committee on Resuscitation (ILCOR)20 identified a number of critical knowledge gaps related to post cardiac arrest syndrome including epidemiology, pathophysiology, therapeutic interventions, prognosis and barriers. In addition, the Australian and New Zealand Committee on Resuscitation (ANZCOR) has made clear statements about the need for a consistent and evidence based approach to post resuscitation care.2
Observations of current clinical practice in Emergency Departments (ED) and Intensive Care Units (ICU) suggest variability in the delivery of post resuscitation care, however objective assessments of the degree of variation are lacking. Currently there are no published Australian studies of post-resuscitation care that span the both ED and ICU management of patients following cardiac arrest.
The aim of this study was to examine the first 24 h of post resuscitation care for patients admitted to the ICU from the ED and to compare the care received with guideline recommended care. For the purposes of this paper, post resuscitation care commenced at the time of Return of Spontaneous Circulation. It should be noted that at the time the following guideline was in place: the ARC Guideline 11.7: Post Resuscitation Therapy in Adult Advanced Life Support.18 The researchers recognise that there is now an updated version of this guideline published since the conclusion of this study.2
Section snippets
Design
A retrospective, descriptive, exploratory approach was used. The study was approved by the Human Research and Ethics Committees at both study sites.
Setting
The retrospective audit was conducted at two major health services in Melbourne, Australia. Site A was a 400 bed acute care hospital that manages approximately 30 cardiac arrest survivors per year in their ED who are subsequently admitted to the ICU. Site B was a 385 bed acute care hospital that manages approximately 50 cardiac arrest survivors per
Results
There were 200 included patients (100 patients per site), with a median age of 64 years (IQR = 54–76) and 74% were males (n = 148). The majority of patients (91.5%, n = 183) suffered an out of hospital cardiac arrest (OOHCA); the remaining 8.5% (n = 17) suffered their cardiac arrest in the ED. The initial rhythm was shockable in 54% of patients (n = 108). Of the 183 patients suffering OOHCA, 71.6% (n = 131) received bystander cardiopulmonary resuscitation (CPR). For all patients, the median time to Return
Discussion
This study found that: (i) the use of FiO2 of 1.0 and hyperoxia was common during the first 24 h of post resuscitation care, (ii) there was variability in cardiac care with timely 12 lead ECG in the ED and the majority of patients achieving SBP of greater than 100 mmHg, but delays in transfer to CCL, (iii) neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide TTM in almost half of patients. Importantly, there were clear associations between in-hospital
Conclusion
Despite evidence-based national and international guidelines, there are high levels of variability in post resuscitation care and guideline adherence is inconsistent. The presence of national guidelines does not necessarily translate to evidence-based care so strategies to ensure effective implementation of research evidence for post resuscitation care practice are urgently required. A large amount of work has led to current evidence-based guidelines. It behoves us to translate this knowledge
Author contributions
A. Milonas: Contributed to the study design, ethics and funding grant applications, data collection, data analysis and interpretation and writing and revising of the manuscript and assumes accountability as corresponding author.
A. Hutchinson: Contributed to the study design, data analysis and interpretation and critical analysis and revision critique of the final manuscript.
A. Doric: Contributed to the study design, critical analysis of the study findings and revision and approval of the final
Acknowledgements
This study was funded by a Northern Health and Eastern Health Research Grant.
References (35)
- et al.
Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke
Resuscitation
(2008) - et al.
Management of the post-cardiac arrest syndrome
J Emerg Med
(2012) - et al.
In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway
Resuscitation
(2003) - et al.
The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology
Resuscitation
(2014) - et al.
Association of blood glucose at admission with outcomes in patients treated with therapeutic hypothermia after cardiac arrest
Am J Emerg Med
(2014) - et al.
Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: review and meta-analysis
Resuscitation
(2014) - et al.
Part 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care on science with treatment recommendations
Resuscitation
(2015) - et al.
Survival and neurologic recovery in patients with ST-Segment Elevation Myocardial Infarction resuscitated from cardiac arrest
J Am Coll Cardiol
(2009) - et al.
Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention
Am Heart J
(2005) - et al.
Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest
Resuscitation
(2013)
The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia
Resuscitation
Post-resuscitation care: current therapeutic concepts
Acute Card Care
Australian Resuscitation Council Guideline 11.7. Post resuscitation therapy in advanced life support. Australia
Post-cardiac arrest syndrome
Minerva Anestesiol
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia
N Engl J Med
Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest
N Engl J Med
Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock
Acta Anaesthesiol Scand
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