Elsevier

Australian Critical Care

Volume 30, Issue 6, November 2017, Pages 299-305
Australian Critical Care

Research paper
Post resuscitation management of cardiac arrest patients in the critical care environment: A retrospective audit of compliance with evidence based guidelines

https://doi.org/10.1016/j.aucc.2016.12.001Get rights and content

Abstract

Background

There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. The Australian Resuscitation Council (ARC) recommends protocol driven care to enhance chance of survival following cardiac arrest. Healthcare providers have an obligation to ensure protocol driven post resuscitation care is timely and evidence based.

Objectives

The aim of this study was to examine adherence to best practice guidelines for post resuscitation care in the first 24 h from Return of Spontaneous Circulation for patients admitted to the intensive care unit from the emergency department having suffered out of hospital or emergency department cardiac arrest and survived initial resuscitation.

Method

A retrospective audit of medical records of patients who met the criteria for survivors of cardiac arrest was conducted at two health services in Melbourne, Australia. Criteria audited were: primary cardiac arrest characteristics, oxygenation and ventilation management, cardiovascular care, neurological care and patient outcomes.

Findings

The four major findings were: (i) use of fraction of inspired oxygen (FiO2) of 1.0 and hyperoxia was common during the first 24 h of post resuscitation management, (ii) there was variability in cardiac care, with timely 12 lead Electrocardiograph and majority of patients achieving systolic blood pressure (SBP) greater than 100 mmHg, but delays in transfer to cardiac catheterisation laboratory, (iii) neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide therapeutic hypothermia in almost 50% of patients and (iv) there was an association between in-hospital mortality and specific elements of post resuscitation care during the first 24 h of hospital admission.

Conclusion

Evidence-based context-specific guidelines for post resuscitation care that span the whole patient journey are needed. Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so strategies to ensure effective guideline implementation are urgently required.

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:

  • Systolic blood pressure (SBP) greater than 100 mmHg with the administration of vasopressors and or intravenous fluids if required.

  • Intubation and ventilation guided by appropriate monitoring to maintain an oxygen saturation of 94–98% and normocarbia.

  • Blood glucose level: frequent monitoring of blood glucose level (BGL) and treatment of hyperglycaemia greater than 10 mmol/L and avoiding hypoglycaemia.

  • Administration of antiarrhythmic medications if required.

  • Induction of therapeutic hypothermia (now TTM) and following rewarming avoiding hyperthermia.

  • Consideration of use of anticonvulsant medications.

  • 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).

  • 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)

  • H.V. Ganga et al.

    The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia

    Resuscitation

    (2013)
  • P. Cokkinos

    Post-resuscitation care: current therapeutic concepts

    Acute Card Care

    (2009)
  • Australian Resuscitation Council Guideline 11.7. Post resuscitation therapy in advanced life support. Australia

    (2016)
  • A. Binks et al.

    Post-cardiac arrest syndrome

    Minerva Anestesiol

    (2010)
  • S.A. Bernard et al.

    Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia

    N Engl J Med

    (2002)
  • The Hypothermia after Cardiac Arrest Study Group

    Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest

    N Engl J Med

    (2002)
  • J. Hovdenes et al.

    Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock

    Acta Anaesthesiol Scand

    (2007)
  • Cited by (11)

    • Does experience in prehospital post-resuscitation critical care affect outcomes? A retrospective cohort study

      2021, Resuscitation
      Citation Excerpt :

      After return of spontaneous circulation (ROSC) the objectives of post-resuscitation care are to reverse any treatable cause for cardiac arrest and stabilize vital functions to prevent end organ damage.4,5 The European Resuscitation Council (ERC) has published guidelines for post-resuscitation care,6 adherence to which has been associated with improved outcomes.7,8 One main objective of Helicopter Emergency Medical Services (HEMS) are to concentrate advanced prehospital critical care, such as post-resuscitation care, to specialized teams.

    • Trapped in a disrupted normality: Survivors’ and partners’ experiences of life after a sudden cardiac arrest

      2020, Resuscitation
      Citation Excerpt :

      The end goal of cardio-pulmonary resuscitation (CPR) is to restore an individual’s quality of life10 returning survivors to an acceptable level of both physical and cognitive function.11,12 Whilst the initial stages of the cardiac arrest care pathway (pre-hospitalisation; emergency and initial critical care) are increasingly prescribed and underpinned by a growing evidence-base,13–15 strategies for post-acute rehabilitation and long-term care are less developed.16,17 Mental health, cognitive and physical impairments, affective disturbances, seizures, movement disorders, and a reduced ability to return to pre-morbid activities are increasingly recognised in survivors.18–22

    View all citing articles on Scopus
    View full text