Session 10ME1 – Return of spontaneous circulation – what next?

Session 10ME1 – Return of spontaneous circulation – what next?

Saturday 2 June, 11:00-12:00, Purple Room

Euroanaesthesia’s first “Meet the Expert” session will be on the return of spontaneous circulation, delivered by Markus Skrifvars, Professor of Pre-hospital Emergency Medicine, University Hospital Helsinki, Finland, and Professor Claudio Sandroni, Catholic University School of Medicine, Rome, Italy,

In his talk on post resuscitation care, Professor Skrifvars will say:Cardiac arrest (CA) is a major medical problem with approximately 350,000 cases annually in Europe. Anaesthesiologists and intensivists play a major role in the management of cardiac arrest patients, but especially so during immediate care in the intensive care unit (ICU). These patients have a deranged physiology but with correct management, the outcome of patients can be improved.”

Important aspects include identifying and managing the cause of the arrest, targeted temperature management (TTM), mechanical ventilation and care of post-arrest organ failures. Very importantly, patient prognosis cannot be reliably assessed immediately after the arrest and therefore care in the ICU is advocated in the absolute majority of CA patients.

Most out-of-hospital cardiac arrests have a cardiac aetiology such as myocardial infarction and immediate angiography and percutaneous coronary intervention is indicated. However, there are other less common causes as well such intracranial hemorrhage, which should be identified early, as ICU care is different. Circulatory shock is a typical feature and related to an inflammatory response very similar to sepsis.

Prof Skrifvars concludes: “Hypotension is detrimental especially during the first 6 hours after the arrest and must be avoided, all patients must be monitored invasively with an arterial line. Fever is common and worsens brain injury and temperature should be controlled with the use of a feedback device. Cerebral ischaemia may be present and but can be influenced with correct ventilator management. Other aspects of care include identification of aspiration pneumonia, sedation, initiation of enteral nutrition and managing electrolyte disorders.”

Professor Sandroni will then discuss prognostication, saying that “more than 80% of patients who are admitted to hospital after resuscitation from cardiac arrest are comatose due to hypoxic-ischaemic brain injury (HIBI) and most of them will die before hospital discharge without having regained consciousness.1  Assessing the severity of HIBI in these patients is essential to predict their prognosis, provide correct information to their families and ensue that proportionate care is given.”

According to the 2015 Guidelines on post-resuscitation care co-issued by the European Resuscitation Council and the European Society of Intensive Care Medicine,2 in patients who are comatose with absent or extensor motor response to pain at 72 hours or more after recovery of spontaneous circulation (ROSC) from cardiac arrest and are treated with targeted temperature management (TTM), a severe neurological disability or death can be predicted with high accuracy and precision based on the bilateral absence of the N20 wave of short-latency somatosensory evoked potentials and/or of pupillary response to light. In absence of indications from these most robust predictors, a combination of two or more less robust predictors can be used. These include a status myoclonus within 48 hours from ROSC, high blood values of neuron specific enolase at 24-72 hours from ROSC, presence of malignant patterns (unresponsive burst-suppression or status epilepticus) on electroencephalogram (EEG) after rewarming from TTM (36-48 hours from ROSC), and signs of severe and diffuse HIBI on brain imaging.

Professor Sandroni concludes: “However, despite a systematic approach to neuroprognostication, in about one third of patients the prognosis remains uncertain after TTM3 and a prolonged clinical observation is recommended.  Strategies aimed to reduce prognostic uncertainty in these patients include avoiding interference from metabolic derangements or prolonged sedation on clinical examination, and standardising clinical tests, for example by using automated detection of pupillary reflex (pupillometry)4 or using standardised or automated EEG analysis. In particular, new malignant patterns on continuous EEG —providing strong prognostic indication within 24 hours from ROSC — have recently been identified5.”

References

  1. Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, Chiche J D, et al. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med 2013; 39:1972-80.
  2. Nolan J P, Soar J, Cariou A, Cronberg T, Moulaert V R, Deakin C D, et al. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care. Intensive Care Med 2015; 41:2039-56.
  3. Dragancea I, Wise M P, Al-Subaie N, Cranshaw J, Friberg H, Glover G, et al. Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management. Resuscitation 2017; 117:50-57.
  4. Solari D, Rossetti A O, Carteron L, Miroz J P, Novy J, Eckert P, et al. Early prediction of coma recovery after cardiac arrest with blinded pupillometry. Ann Neurol 2017; 81:804-810.
  5. Rossetti A O, Tovar Quiroga D F, Juan E, Novy J, White R D, Ben-Hamouda N, et al. Electroencephalography Predicts Poor and Good Outcomes After Cardiac Arrest: A Two-Center Study. Crit Care Med 2017; 45:e674-e682.