Post-Resuscitation Care Guideline

Overview

This specialist Guidelines summary includes recommendations on adult post resuscitation care, diagnosis of cause of cardiac arrest, and prognostication.

This summary is intended for use in a secondary care setting by cardiologists. For further information, please refer to the full guideline.

Management of cardiac arrest in patients with known or suspected COVID-19 is not specifically included in this guideline, but is covered within RCUK’s separate COVID-19 guidance.

Key Points

This guideline was updated in 2021. Key changes from the 2015 guideline are:

• Alignment with European Society of Cardiology guidelines for the indications for immediate coronary angiography in post-resuscitation patients without ST-elevation on their 12-lead electrocardiogram (ECG)
• Following return of spontaneous circulation (ROSC), aim to maintain a mean arterial blood pressure of >65 mmHg. Over this threshold optimal blood pressure targets are likely to need to be optimised
• Levetiracetam and sodium valproate are preferred instead of phenytoin for the treatment of seizures
• Targeted temperature management (TTM) is recommended for adults after either out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) with any initial rhythm who remain unresponsive after ROSC
• Maintain a target temperature at a constant value between 32°C and 36°C for at least 24 hours
• Avoid fever (>37.7°C) for at least 72 hours after ROSC in patients who remain in coma
• The multimodal prognostication guidelines have been updated. In a comatose patient with a Glasgow Motor Score of M ≤3 at ≥72 hours from ROSC, in the absence of confounders, poor outcome is likely when two or more of the following predictors are present:
  • no pupillary and corneal reflexes at ≥72 hours
  • bilaterally absent N20 SSEP wave at ≥24 hours
  • highly malignant electroencephalogram (EEG) (suppressed background or burst suppression) at ≥24 hours
  • NSE >60 mcg L^-1 at 48 hours and/or 72 hours
  • status myoclonus ≤72 hours
  • or a diffuse and extensive anoxic injury on brain CT/MRI
• Greater emphasis is placed on screening cardiac arrest survivors for physical, cognitive, and emotional problems and, where indicated, referring for rehabilitation.

Immediate Post-Resuscitation Care 

• Post-resuscitation care is started immediately after sustained ROSC, regardless of location
• Following out-of-hospital cardiac arrest, consider transport to a recognised centre of care (for example, cardiac arrest centre)

Algorithm 1: Adult Post Resuscitation Care

Diagnosis of Cause of Cardiac Arrest 

• If there is clinical (for example, haemodynamic instability) or ECG evidence of myocardial ischaemia, undertake coronary angiography first. This is followed by computed tomography (CT) brain and/or CT pulmonary angiography if coronary angiography fails to identify causative lesions
• Early identification of a respiratory or neurological cause can be achieved by performing a brain and chest CT-scan at hospital admission, before or after coronary angiography (see coronary reperfusion in the Circulation section)
• If there are signs or symptoms pre-arrest suggesting a neurological or respiratory cause (for example, headache, seizures, or neurological deficits, shortness of breath or documented hypoxaemia in patients with known respiratory disease), perform a CT brain and/or a CT pulmonary angiogram. 

Airway and Breathing 

Airway Management After Return of Spontaneous Circulation 

• Airway and ventilation support should continue after ROSC is achieved
• Patients who have had a brief period of cardiac arrest and an immediate return of normal cerebral function and are breathing normally may not require tracheal intubation but should be given oxygen via a face mask if their arterial blood oxygen saturation is <94%
• Patients who remain comatose following ROSC, or who have another clinical indication for sedation and mechanical ventilation, should have their trachea intubated if this has not been done already during cardiopulmonary resuscitation (CPR)
• Tracheal intubation should be performed only by experienced operators who have a high success rate
• Correct placement of the tracheal tube must be confirmed with waveform capnography
• In the absence of personnel experienced in tracheal intubation, it is reasonable to insert a supraglottic airway or maintain the airway with basic techniques until skilled intubators are available. 

Control of Oxygenation 

• After ROSC, use 100% (or maximum available) inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably
• After ROSC, once oxygen saturation (SpO₂) can be measured reliably or arterial blood gas values are obtained, titrate the inspired oxygen to achieve an arterial oxygen saturation of 94–98% or arterial partial pressure of oxygen (PaO₂) of 10–13 kPa or 75–100 mmHg
• Avoid hypoxaemia (PaO₂ <8 kPa or 60 mmHg) following ROSC
• Avoid hyperoxaemia following ROSC. 

Control of Ventilation  

• Obtain an arterial blood gas and use end tidal CO₂ in mechanically ventilated patients
• In patients requiring mechanical ventilation after ROSC, adjust ventilation to target a normal arterial partial pressure of carbon dioxide (PaCO₂), that is, 4.5–6.0 kPa or 35–45 mmHg
• In patients treated with TTM, monitor PaCO₂ frequently as hypocapnia may occur
• During TTM and lower temperatures, use consistently either a temperature or non-temperature corrected approach for measuring blood gas values
• Use a lung protective ventilation strategy aiming for a tidal volume of 6–8 ml per kg ideal body weight.  

Circulation  

Coronary Reperfusion 

• Emergent cardiac catheterisation laboratory evaluation (and immediate percutaneous coronary intervention if required) should be performed in adult patients with ROSC after cardiac arrest of suspected cardiac origin with ST-elevation on the ECG
• In patients with ROSC after OHCA without ST-elevation on the ECG, emergent cardiac catheterisation laboratory evaluation should be considered if there is an estimated high probability of acute coronary occlusion (for example, patients with haemodynamic and/or electrical instability). 

Haemodynamic Monitoring and Management 

• All patients should be monitored with an arterial line for continuous blood pressure measurements, and it is reasonable to monitor cardiac output in haemodynamically unstable patients
• Perform early (as soon as possible) echocardiography in all patients to detect any underlying cardiac pathology and quantify the degree of myocardial dysfunction
• Avoid hypotension (blood pressure under 65 mmHg). Target mean arterial pressure to achieve adequate urine output (over 0.5 ml per kg per hour) and normal or decreasing lactate
• During TTM at 33°C, bradycardia may be left untreated if blood pressure, lactate, central venous oxygen saturation or venous oxygen saturation (ScvO₂ or SvO₂) is adequate. If not, consider increasing the target temperature, but to no higher than 36°C
• Maintain perfusion with fluids, noradrenaline and/or dobutamine, depending on individual patient need for intravascular volume, vasoconstriction, or inotropy
• Do not give steroids routinely after cardiac arrest
• Avoid hypokalaemia, which is associated with ventricular arrhythmias
• Consider mechanical circulatory support (such as intra-aortic balloon pump, left-ventricular assist device or arterio-venous extra corporal membrane oxygenation) for persisting cardiogenic shock from left ventricular failure if treatment with fluid resuscitation, inotropes, and vasoactive drugs is insufficient. Left-ventricular assist devices or arterio-venous extra corporal membrane oxygenation should also be considered in haemodynamically unstable patients with acute coronary syndromes and recurrent ventricular tachycardia or ventricular fibrillation despite optimal therapy. 

Disability (Optimising Neurological Recovery) 

Control of Seizures 

• Resuscitation Council UK (RCUK) recommends using EEG to diagnose electrographic seizures in patients with clinical convulsions and to monitor treatment effects
• To treat seizures after cardiac arrest, RCUK suggests levetiracetam or sodium valproate as first-line antiepileptic drugs in addition to sedative drugs
• RCUK suggests that routine seizure prophylaxis is not used in post-cardiac arrest patients. 

Temperature Control 

• RCUK recommends TTM for adults after either OHCA or IHCA, with any initial rhythm, who remain unresponsive after ROSC
• Maintain a target temperature at a constant value between 32°C and 36°C for at least 24 hours
• Avoid fever (temperature over 37.7°C) for at least 72 hours after ROSC in patients who remain in coma
• Do not use pre-hospital intravenous cold fluids to initiate hypothermia. 

General Intensive Care Management 

• Use short-acting sedatives and opioids
• Avoid using a neuromuscular blocking drug routinely in patients undergoing TTM, but it may be considered in case of severe shivering during TTM
• Provide stress ulcer prophylaxis routinely in cardiac arrest patients
• Provide deep venous thrombosis prophylaxis
• Target a blood glucose of 7.8–10 mmol/l using an infusion of insulin if required; avoid hypoglycaemia (<4.0 mmol/l) 
• Start enteral feeding at low rates (trophic feeding) during TTM and increase after rewarming if indicated. If TTM of 36°C is used as the target temperature, gastric feeding rates may be increased early during TTM
• RCUK does not recommend using prophylactic antibiotics routinely. 

Prognostication 

General Guidelines 

• In patients who are comatose after resuscitation from cardiac arrest, neurological prognostication should be performed using clinical examination, electrophysiology, biomarkers, and imaging, to both inform the patient’s relatives and to help clinicians to target treatments based on the patient’s chances of achieving a neurologically meaningful recovery 
• No single predictor is 100% accurate. Therefore, a multimodal neuroprognostication strategy is recommended
• When predicting poor neurological outcome, a high specificity and precision are desirable, to avoid falsely pessimistic predictions
• The clinical neurological examination is central to prognostication. To avoid falsely pessimistic predictions, clinicians should avoid potential confounding from sedatives and other drugs that may confound the results of the tests
• When patients are treated with TTM, daily clinical examination is advocated but final prognostic assessment should be undertaken only after rewarming
• Clinicians must be aware of the risk of a self-fulfilling prophecy bias, occurring when the results of an index test predicting poor outcome is used for treatment decisions, especially regarding life-sustaining therapies
• Tests for neurological prognostication are aimed at assessing the severity of hypoxic-ischaemic brain injury. The neurological prognosis is one of several aspects to consider in discussions around an individual’s potential for recovery. 

Multimodal Prognostication

• Start the prognostication assessment with an accurate clinical examination, to be performed only after major confounders (for example, residual sedation, hypothermia) have been excluded
• In a comatose patient with a motor response (M) of three or less at 72 hours or more from ROSC, in the absence of confounders, poor outcome is likely when two or more of the following predictors are present: no pupillary and corneal reflexes at 72 hours or more, bilaterally absent N20 somatosensory evoked potential (SSEP) wave at 24 hours or more, highly malignant EEG at over 24 hours, neuron-specific enolase (NSE) >60 mcg/l at 48 hours and/or 72 hours, status myoclonus 72 hours or less, or a diffuse and extensive anoxic injury on brain CT/MRI. Most of these signs can be recorded before 72 hours from ROSC; however, their results will be evaluated only at the time of clinical prognostic assessment. 

Algorithm 2: Neuroprognostication of the Comatose Adult Patient After Resuscitation from Cardiac Arrest

Withdrawal of Life-Sustaining Therapy  

• Separate discussions around withdrawal of life-sustaining therapy (WLST) and the assessment of prognosis for neurological recovery; WLST decisions should consider aspects other than brain injury such as age, comorbidity, general organ function, and the patient’s preferences
• Allocate sufficient time for communication around the level-of-treatment decision within the team and with the relatives. 

Long-Term Outcome After Cardiac Arrest 

• Perform functional assessments of physical and non-physical impairments before discharge from the hospital to identify early rehabilitation needs and refer to rehabilitation if necessary 
• Organise follow-up for all cardiac arrest survivors within 3 months after hospital discharge, including: 
  1. screening for cognitive problems
  2. screening for emotional problems and fatigue
  3. providing information and support for survivors and family members. 

Organ Donation 

• All decisions concerning organ donation must follow local legal and ethical requirements
• Organ donation should be considered in those who have achieved ROSC and who fulfil neurological criteria for death
• In comatose ventilated patients who do not fulfil neurological criteria for death, if a decision to start end-of-life care and withdrawal of life support is made, organ donation should be considered for when circulatory arrest occurs. 

Algorithm 3: Organ Donation after Cardiac Arrest

Recognised Centres of Care

• Adult patients with non-traumatic OHCA should be considered for transport to a recognised centre of care (for example, cardiac arrest centre or heart attack centre) for appropriate specialist treatment, according to local protocols
• Adult patients with a cardiac arrest of presumed cardiac aetiology should be transported directly to a hospital with 24/7 coronary angiography capability.