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

1. Post cardiac arrest ICU care

7. 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.

8. 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.

9. 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.

10. 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.

11. Early coronary reperfusion

12. PROCAT
Parisian Region Out of hospital Cardiac ArresT
Registry
Dumas F. Circ
Cardiovasc Interv
2010;3:200-7
714 OHCA admitted to ICU
714 OHCA admitted to ICU
No obvious extra-cardiac cause
No obvious extra-cardiac cause
(n = 435)
(n = 435)
STEMI
STEMI
N = 134 (31%)
N = 134 (31%)
Other ECG
Other ECG
N = 301 (69%)
N = 301 (69%)
≥ coronary lesion
≥ coronary lesion
N = 128 (96%)
N = 128 (96%)
≥ coronary lesion
≥ coronary lesion
N = 176 (58%)
N = 176 (58%)
Successful PCI
Successful PCI
N = 99 (74%)
N = 99 (74%)
Successful PCI
Successful PCI
N = 78 (26%)
N = 78 (26%)
Successful angioplasty independent predictor survival OR 2.06 (1.16 to 3.66)

13. 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)
100 (94 – 100)
46 (36 – 56)
As above + LBBB or
nonspecific QRS complexes (n = 116)
Angiographic AMI in 60 (36%) patients
Resuscitation 2011;82:1148-53

14. PCI after cardiac arrest
ST 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. JJ Am Coll Cardiol Intv 2012;5:597-605
Kern KB. Am Coll Cardiol Intv 2012;5:597-605

16. Mechanisms of ischemia/reperfusion injury.
Levitsky S Circulation 2006;114:I-339-I-343
Copyright © American Heart Association

17. Enteral nutrition
Insulin
Cooling
Inotropes
Defibrillator
Ventilation
Pacing
IABP

18. Mode of death after admission to
ITU following cardiac arrest
126 (62%) deaths out
of 206 admissions
Laver S. Intensive Care Med 2004; 30:2126-8
Laver S. Intensive Care Med 2004; 30:2126-8

19. Improving neurological outcome
after cardiac arrest
•
•
•
•
•
Controlled re-oxygenation
Cerebral perfusion
Glucose control
Control of seizures
Targeted temperature
management

20. Airway and breathing with
controlled re-oxygenation

21. In-hospital mortality n (%) [95% CI]*
*P<0.001
hyperoxia vs. normoxia and
hyperoxia vs. hypoxia

22. Circulation 2011;123:2717-2722

23. 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

24. 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%.”

27. 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

28. Target Temperature Management the TTM trial
Clinicaltrials.gov: NCT01020916
www.ttm-trial.org
info@ttm-trial.org
Results embargoed-17th Nov to be presented at the AHA
Target Temperature Management after out-of-hospital cardiac arrest-a
randomized, parallel-group, assessor-blinded clinical trial rationale and design.
Am Heart J. 2012;163(4):541-8

29. Therapeutic hypothermia
after cardiac arrest
An Advisory Statement by the ALS Task Force of the
International Liaison Committee on Resuscitation (ILCOR)
• 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

30. Knowledge gaps
What rhythms?
When to start cooling?
What technique?
How long?
A
B

31. Cerebral resuscitation
•
Sedation
– propofol, fentanyl
– Clearance of many drugs is reduced by a third at 34 oC
•
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

32. Prognostication

33. 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)

35. SSEPs

36. 36 patients with absent N20 – 2 good recoveries
Leithner C. Neurology 2010;74:965-9

38. 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.

39. 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

41. 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.

42. 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.