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Written by Aaron Lacy
Buckle up, we have a lot to talk about today!
Today we are covering a new, joint scientific statement from the American Heart Association and Neurocritical Care Society regarding care of patients who suffered cardiac arrest and subsequently had ROSC.
The journey of 1,000 miles starts with a single ROSC, or something like that
This article is 33 pages long, has 274 references, and lists 76 statements (oof). Going by organ system, I am going to highlight what I found to be the most important, interesting, or practice changing in each section. See the source at the bottom of the article to review all the statements yourself.
Neuro
- Brain oxygenation, perfusion, edema, and ICP
- Avoid the urge for 100% arterial oxygenation. Target a range of 92-98%.
- Seizures and the Ictal-Interictal Continuum
- I swear there is only 1 EEG tech per hospital. However, the recommendations are to monitor for seizure activity via EEG as soon as possible after cardiac arrest, so track that tech down!
- Sedation
- Short acting sedatives and analgesics (i.e. propofol and fentanyl) are preferred over long-acting agents (i.e. midazolam and morphine) to help reduce intubation time and prognostication (and importantly, delirium)
- Early Prognostication
- The authors emphasize that early prognostication is fraught with difficulty and inaccuracies. However, early risk assessment can help guide appropriate clinical interventions. So, avoid prognostication with patients and their family, but do try to gather early information to help guide patient care.
Cardiac
- Monitoring
- Get an echo on the patient as soon as possible to help guide resus. If you have the training for this, do it yourself instead of waiting for the tech.
- No blanket blood pressure goals were made, which makes sense. Each patient’s MAP goals and medications to get them there are highly individualized. If you have refractory hypoperfusion, get evaluation for mechanical support early (ECMO, balloon pump, etc.)
- Cardiac Cath
- This one was interesting to me. Despite murky literature (see here, here, and here) on whether we should be getting early cath on all non-STEMI patients with ROSC, and the authors admitting research isn’t definitive, they still had 22/23 recommend getting early (under 6 hours!!) catheterization on patients without ST changes on ECG post ROSC. I think it’s important to discuss this with your cardiologist, but for my practice probably not a hill I will die on if they don’t want to take them emergently.
Pulmonary
- Oxygenation and ventilation
- Again, target 92-98%. In general, target a PaCO2 of 35-45 mm Hg, but you can alter this slightly to help maintain a pH >7.2 in select patients (think hypocapnia in patients with severe metabolic acidosis that is otherwise being treated). For me, it’s just a matter of timing the blood gas correctly in the ED to make effective changes – work closely with your RRT and nurses on this
Heme
- Transfusion
- The authors recommend considering higher hemoglobin transfusion thresholds (<9 g/dL) in patients with acute coronary disease. We recently covered the MINT trial, which was not out during the development of this consensus statement. I will consider case by case basis.
- VTE Prophylaxis
- Get it started in the first 48 hours, and low-molecular-weight heparin is preferred unless they have renal dysfunction
GI
- Nutrition
- Even in patients with shock, starting enteral nutrition (low and slow) should be a priority after getting to the ICU.
Infectious Disease
- Antibiotics
- The guidelines specifically say it’s reasonable to give prophylactic antibiotics in patients who are getting targeted temperature management post-arrest. While I know the literature is not perfect in support of empiric antibiotics for all, the patients in the ED are often so undifferentiated I likely will continue to be liberal in my administration of them.
Endocrine
- Fluids
- Ahh fluids, no controversy here, right? I am a balanced crystalloids person and believe most literature trends in this direction. However, as noted by the authors, there are no studies on fluids in the post-arrest population. Normal saline is better for patients with cerebral edema and intracranial trauma. Cerebral edema is common in hypoxia, which many arrest patients will have, so think carefully about your fluid choice in these patients, balancing neurons vs nephrons.
- Sodium bicarb
- I know there are people out there still giving sodium bicarb for mild to moderate metabolic acidosis. Resist the urge, and only consider in patients with severe acidosis (pH <7.2) and stage 2 or 3 AKI.
General
- Logistics
- Protocols are important. As noted by the volume of this article alone, there is a ton to do and consider in post-arrest patients. In fact, just having a protocol in place is more important than the individual components of the protocol – they increase adherence and promote interdisciplinary management of these patients. If you don’t have some post-arrest protocols in your ED or ICU, sounds like it’s time to create a new committee.
How will this change my practice?
I work in the emergency department, so it is unfeasible to implement and monitor all 76 of these consensus statements myself, and I can’t necessarily complete a FAST HUGS BID assessment on my patients. However, this article has reminded me that I need to be reviewing our post-arrest protocols and thinking about order sets/protocols that may be missing I can start right away. For the many JournalFeed readers who work in the ICU, I expect you will be doing a lot more based on these recommendations than I can.
I will be focusing on:
- Trying to get EEG monitoring on board sooner rather than later, as I probably have been missing some seizure activity that needs treatment in these patients.
- Continuing to avoid benzos and morphine for sedation unless specifically indicated.
- Doing point of care cardiac ultrasound in the ED to help guide my interventions while awaiting formal studies.
- While not mentioned in the article, post-arrest “pan-scanning” (I mean, I’m an ED doc, can’t help myself) if the etiology is unclear. Many of the consensus statements are conditional on the presumptive diagnosis, which I often don’t have. Expediting a diagnosis can help get the proper care started early.
- Protocols, protocols, protocols, and interdisciplinary management
Source
Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation. 2023 Nov 28. doi: 10.1161/CIR.0000000000001163. Online ahead of print.
