Editorial

Post resuscitation care—Time for a care bundle?

A study was made of the events occurring in the early post-resuscitation phase that may help to improve the outcomes at hospital discharge.

A retrospective cohort study (2007–2017) of a prospective Utstein type registry database was carried using multivariate logistic regression analysis. Pre- and post-hospital admission events were investigated.

A tertiary cardiac centre.

Unconscious victims of out-of-hospital cardiac arrest (OHCA) with documented ventricular tachycardia or fibrillation.

Events occurring before and within 72 h after intensive care unit (ICU) admission were recorded. The variables were analyzed to determine their impact on hospital survival and poor neurological outcome. One-year follow-up survival was also considered. Results are presented as odds ratio (OR) and 95% confidence interval (95%CI).

Of 245 patients admitted to our ICU after OHCA, 152 (62%) were alive and 131 (86.2%) presented good neurological outcomes (cerebral performance categories ≤ 2) at hospital discharge. The one-year follow-up survival rate was 95.9%. Age >70 years (OR 2.0; 95%CI 1.1–4.1), previous myocardial infarction (OR 2.7; 95%CI 1.2–6.1), shock upon hospital admission (OR 2.9; 95%CI 1.3–6.2), time from call to return of spontaneous circulation (ROSC) >25 min (OR 3.1; 95%CI 1.6–6.0) and anticonvulsant therapy (OR 18.2; 95%CI 5.5–60) were independent predictors of poor neurological outcome. Immediate admission to the cardiac centre (OR 0.5; 95%CI 0.3–0.9) and lactate clearance reaching plasma levels <2.5 mmol/l at 12 h (OR 0.4; 95%CI 0.2–0.8) were associated with better outcomes.

Unconscious OHCA patients with documented ventricular tachycardia or fibrillation may benefit from direct admission to a reference cardiac centre. Initial haemodynamic support, urgent coronary angiography and targeted management in the cardiac ICU seem to increase the likelihood of good neurological outcomes.

Llevar a cabo un estudio de los acontecimientos ocurridos en la fase inmediatamente posterior a la reanimación que puedan ayudar a mejorar los desenlaces en el momento del alta hospitalaria.

Se realizó un estudio retrospectivo (2007-2017) de cohorte de una base de datos de registro de tipo Utstein prospectivo mediante un análisis de regresión logística multivariable. Se investigaron los acontecimientos previos y posteriores al ingreso hospitalario.

Un centro de atención cardíaca terciaria.

Víctimas inconscientes de parada cardíaca extrahospitalaria (OHCA) con fibrilación o taquicardia ventricular documentada.

Se registraron los acontecimientos ocurridos antes y durante las 72 h posteriores al ingreso en la unidad de cuidados intensivos (UCI). Se analizaron las variables para determinar su impacto en la supervivencia hospitalaria y los malos desenlaces neurológicos. También se tuvo en consideración la supervivencia en el seguimiento a lo largo de un año. Los resultados se presentan con valores de oportunidad relativa (OR) e intervalo de confianza del 95% (IC del 95%).

De los 245 pacientes ingresados en nuestra UCI tras una OHCA, 152 (62%) seguían vivos y 131 (86,2%) presentaban unos buenos desenlaces neurológicos (categorías de rendimiento cerebral ≤ 2) en el momento del alta hospitalaria. La tasa de supervivencia en el seguimiento a lo largo de un año fue del 95,9%. La edad > 70 años (OR: 2,0; IC del 95%: 1,1-4,1), los antecedentes de infarto de miocardio (OR: 2,7; IC del 95%: 1,2-6,1), el choque en el momento del ingreso hospitalario (OR: 2,9; IC del 95%: 1,3-6,2), el tiempo transcurrido entre la llamada y el regreso a la circulación espontánea (ROSC) > 25 min (OR: 3,1; IC del 95%: 1,6-6,0) y la administración de tratamiento anticonvulsivo (OR: 18,2; IC del 95%: 5,5-60) fueron factores predictivos independientes de un mal desenlace neurológico. El ingreso inmediato en un centro de cuidados cardíacos (OR: 0,5; IC del 95%: 0,3-0,9) y el hecho de que el aclaramiento de lactato alcanzase unos niveles plasmáticos < 2,5 mmol/l al cabo de 12 h (OR: 0,4; IC del 95%: 0,2-0,8) se asociaron con unos mejores desenlaces.

Los pacientes inconscientes tras OHCA y con fibrilación o taquicardia ventricular documentada podrían beneficiarse del ingreso directo en un centro cardíaco de referencia. El apoyo hemodinámico inicial, la angiografía coronaria urgente y el tratamiento dirigido en la UCI cardíaca parecen aumentar la probabilidad de obtener unos buenos desenlaces neurológicos.

To perform a systematic review to answer ‘In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?’

The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369)

We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68–12.48) and survival to 30 days (OR 2.14, 95% CI 0.73–6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74–2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46–2.34).

Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.

Out of hospital cardiac arrest (OHCA) is associated with a low rate of survival to hospital discharge and high rates of neurological morbidity among survivors. Programmatic efforts to institute and integrate OHCA best care practices from the bystander response through to the in-hospital phase have been associated with improved patient outcomes. This Canadian Cardiovascular Society position statement was developed to provide comprehensive yet practical recommendations to guide the in-hospital care of OHCA patients. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system recommendations have been generated. Recommendations on initial care delivery on the basis of presenting rhythm, appropriate use of targeted temperature management, postarrest angiography, and revascularization in the initial phase of care of the OHCA patient are detailed within this statement. In addition, further description of best practices on sedation, use of neuromuscular blockade, oxygenation targets, hemodynamic monitoring, and blood product transfusion triggers in the critical care environment are contained in this document. Last, discussion of optimal care systems for the OHCA patient is provided. These guidelines aim to serve as a practical guide to optimize the in-hospital care of survivors of cardiac arrest and encourage the adoption of “best practice” protocols and treatment pathways. Emphasis is placed on integrating these aspects of in-hospital care as part of a postarrest “care bundle.” It is hoped that this position statement can assist all medical professionals who treat survivors of cardiac arrest.

L'arrêt cardiaque extrahospitalier (ACEH) est à l'origine d'une importante mortalité et morbidité, en particulier neurologique. La mise en place de programmes spécifiques pour améliorer les pratiques actuelles, à la fois au niveau de la réponse immédiate du public mais également de la phase intra-hospitalière ont été associés à une réduction de la morbidité et mortalité des patients. Cet énoncé de position de la Société canadienne de cardiologie a été développé afin de guider les soins hospitaliers de patients post ACEH. En utilisant le système GRADE (Grading of Recommendations Assessment, Development and Evaluation), des recommandations détaillées ont été développées sur les soins à apporter selon le rythme initial, l'utilisation appropriée d'hypothermie thérapeutique, la coronarographie et les indications de revascularisation post-arrêt cardiaque. De plus, on retrouve des recommandations sur la sédation, l'utilisation de curares, les cibles d'oxygénation, la surveillance hémodynamique et les cibles de transfusions sanguines aux soins intensifs. Finalement, une discussion sur les systèmes de soins optimaux pour le patient pris en charge pour l'ACEH est inclus. Ces recommandations sont un guide pratique pour optimiser les soins intra-hospitaliers des survivants d'un ACEH et encouragent l'adoption de protocoles de meilleure pratique et un cheminement thérapeutique optimal, en insistant sur l'intégration de tous ces aspects dans la mise en place d'un ensemble de stratégies permettant l'optimisation de la prise en charge. Il est souhaité que cet énoncé de position puisse constituer un outil efficace pour assister les professionnels de la santé qui soignent les survivants d'un arrêt cardiaque.

Evidence to guide initial emergency nursing care of patients with severe traumatic brain injury (TBI) in Thailand is currently not available in a useable form. A care bundle was used to summarise an evidence-based approach to the initial emergency nursing management of patients with severe TBI and was implemented in one Thai emergency department. The aim of this study was to describe Thai emergency nurses' perceptions of care bundle use. A descriptive qualitative study was used to describe emergency nurses' perceptions of care bundle use during the implementation phase (Phase-One) and then post-implementation (Phase-Two). Ten emergency nurses participated in Phase-One, while 12 nurses participated in Phase-Two. In Phase-One, there were five important factors identified in relation to use of the care bundle including quality of care, competing priorities, inadequate equipment, agitated patients, and teamwork. In Phase Two, participants perceived that using the care bundle helped them to improve quality of care, increased nurses' knowledge, skills, and confidence. Care bundles are one strategy to increase integration of research evidence into clinical practice and facilitate healthcare providers to deliver optimal patient care in busy environments with limited resources.

In analogy with sepsis, current post-cardiac arrest (CA) guidelines recommend to target mean arterial pressure (MAP) above 65 mmHg and SVO₂ above 70%. This is unsupported by mortality or cerebral perfusion data. The aim of this study was to explore the associations between MAP, SVO₂, cerebral oxygenation and survival.

Prospective, observational study during therapeutic hypothermia (24 h – 33 °C) in 82 post-CA patients monitored with near-infrared spectroscopy.

Forty-three patients (52%) survived in CPC 1–2 until 180 days post-CA. The mean MAP range associated with maximal survival was 76–86 mmHg (OR 2.63, 95%CI [1.01; 6.88], p = 0.04). The mean SVO₂ range associated with maximal survival was 67–72% (OR 8.23, 95%CI [2.07; 32.68], p = 0.001). In two separate multivariate models, a mean MAP (OR 3.72, 95% CI [1.11; 12.50], p = 0.03) and a mean SVO₂ (OR 10.32, 95% CI [2.03; 52.60], p = 0.001) in the optimal range persisted as independently associated with increased survival. Based on more than 1 625 000 data points, we found a strong linear relation between SVO₂ (range 40–90%) and average cerebral saturation (R² 0.86) and between MAP and average cerebral saturation for MAP's between 45 and 101 mmHg (R² 0.83). Based on our hemodynamic model, the MAP and SVO₂ ranges associated with optimal cerebral oxygenation were determined to be 87–101 mmHg and 70–75%.

we showed that a MAP range between 76–86 mmHg and SVO₂ range between 67% and 72% were associated with maximal survival. Optimal cerebral saturation was achieved with a MAP between 87–101 mmHg and a SVO₂ between 70% and 75%. Prospective interventional studies are needed to investigate whether forcing MAP and SVO₂ in the suggested range with additional pharmacological support would improve outcome.

Hypoxic ischaemic brain injury (HIBI) is a major cause of disability after cardiac arrest. HIBI leads to impaired cerebral autoregulation such that adequate cerebral perfusion becomes critically dependent on blood pressure. However, the optimal blood pressure after cardiac arrest remains unclear. Therefore, we conducted a systematic review to investigate the association between blood pressure and neurologic outcome patients after cardiac arrest.

We systematically searched MEDLINE, EMBASE, conference abstracts and article references to identify randomized and observational studies investigating the relationship between blood pressure and neurologic outcome. We included studies that reported adjusted point estimates for the relationship between blood pressure and neurologic status in adult patients after cardiac arrest.

We included 9 studies with a total of 13,150 patients. Three studies included only patients with an out-of-hospital cardiac arrest. There was marked between-study heterogeneity with respect to blood pressure definition (MAP vs. systolic), exposure duration and modelling (dichotomous vs. continuous). All studies examined either mortality or neurological status as an outcome. Seven of nine studies demonstrated that higher blood pressure was associated with improved outcomes either by an association between higher MAP and good neurologic outcome or the presence of hypotension and increased odds of mortality.

The included studies suggest improved neurologic outcomes are associated with higher blood pressures in patients after cardiac arrest. This study highlights a need for further research to define the optimal management of blood pressure in this population.