Critical Care Management of Patients After Cardiac Arrest

Publication Date: November 27, 2023
Last Updated: December 1, 2023

Brain Oxygenation, Perfusion, Edema, and ICP Statements

  1. To prevent or treat secondary brain hypoxia in comatose CA survivors, optimize cerebral oxygen delivery by maintaining optimal CPP, arterial normo-capnia, and adequate arterial oxygen content while avoiding arterial hyperoxemia (90.5%, 19/21).
  2. To optimize cerebral oxygen delivery in comatose post-CA survivors, maintain hemoglobin >7 g/dL and arterial oxyhemoglobin saturation between 92% and 98% (85.7%, 18/21; see also section on hematologic management).
  3. In comatose CA survivors, continuous monitoring for secondary brain hypoxia may be used in ICUs where validated techniques are in routine use, when there are no contraindications, and when invasive monitoring is consistent with the goals of care (100%, 18/18).
  4. In ICUs where advanced cerebral monitoring is not in routine use, target an MAP >80 mm Hg unless there are clinical concerns or evidence of adverse consequences (82.6%, 19/23).
  5. In ICUs where noninvasive monitoring of cerebral autoregulation is in routine use, maintain MAP at or near the predicted MAPOPT (88.2%, 15/17).
  6. In comatose CA survivors with clinical indicators of cerebral edema and elevated ICP (as measured by head computed tomography, optic nerve ultra-sound, or deterioration of clinical examination), consider invasive ICP monitoring in clinical envi-ronments familiar with the technique if there are no contraindications and invasive monitoring is consistent with the goals of care (81%, 17/21).
  7. In settings where invasive ICP monitoring is in rou-tine use, maintain MAP at or near the predicted MAPOPT by using the pressure reactivity index (100%, 17/17).
  8. Comatose CA survivors with elevated ICP may benefit from pharmacological and nonpharmaco-logical strategies to lower ICP in the critical care environment (85.7%, 18/21).

EEG Monitoring and Seizures Statements

  1. Monitor for seizures and SE with EEG as early as possible after CA and during the rewarming phase if temperature control with a hypothermic temperature target is used. Continue EEG moni-toring for 72 to 120 hours after CA in patients who fail to recover consciousness. If seizures or SE is diagnosed, the duration and frequency of EEG monitoring are individualized on the basis of treatment goals (85%, 17/20).
  2. Monitor patients who fail to recover conscious-ness with cEEG to screen for seizures or SE. Intermittent EEG monitoring can be considered as an alternative monitoring modality, depending on the resources of a given institution (100%, 19/19).
  3. In patients undergoing intermittent EEG moni-toring, obtain EEGs daily during the first 72 to 120 hours after CA in patients who fail to recover consciousness (90%, 18/20).
  4. Continue cEEG monitoring for at least 24 hours after post-CA seizures or SE initially abate elec-trographically in patients who fail to recover consciousness because of the possibility of nonconvulsive seizures or SE in this population (100%, 19/19).
  5. Consider transfer to a center that can perform EEG monitoring in patients suitable for trans-fer who fail to recover consciousness after CA (90%, 18/20).
  6. Consider quantitative EEG trends such as spec-trograms and amplitude-integrated EEG as an adjunctive monitoring strategy for seizure screening (84%, 16/19).
  7. Interpret the EEG as soon as possible after the recording is started, and report results rapidly to the team in charge of medical management (95%, 19/20).
  8. Ensure that written EEG reports are updated at least daily and are available to the team in charge of medical management (90%, 18/20).
  9. Consider the clinical context of patient manage-ment in the interpretation of EEG and written report of EEG findings, including factors such as clinical examination, use of sedatives and ASMs, and hemodynamic and metabolic factors (95%, 19/20).
  10. Follow the same treatment standards used for other causes of seizures or SE in patients with post-CA seizures or SE, assuming that the goals of care are compatible with aggressive treatment (95%, 19/20).
  11. Evaluate and treat seizures or SE after CA in the context of other available clinical information because other systemic factors may influence the occurrence of seizures or SE and the effec-tiveness of treatment (90%, 18/20).
  12. The treatment goal for post-CA SE is seizure suppression or burst suppression for a minimum of 24 hours (95%, 19/20).
  13. Valproic acid and levetiracetam are reasonable first-line agents for seizure treatment after CA (84%, 16/19).
  14. Valproic acid and levetiracetam are reasonable first-line agents for treatment of electroclinical myoclonus or electrographic seizures or SE with electroclinical myoclonus after CA. Clonazepam can be effective, but its sedative effects may con-found neurological examination (100%, 20/20).
  15. Do not aggressively treat clinical myoclonus with-out electrographic correlate unless myoclonic activity interferes with other aspects of care (eg, ventilation) (100%, 24/24).
  16. Do not continue temperature control with a hypo-thermic target specifically for the treatment of seizures or SE after CA (85%, 17/20).
  17. A full-montage EEG is most sensitive to capture seizures. Limited-montage EEG may be used in select settings (100%, 17/17)

IIC Statements

  1. IIC patterns, defined by American Clinical Neurophysiology Society criteria, may have a higher likelihood of representing ictal activity and thus justify more aggressive treatment, further imaging, and/or the addition of invasive EEG moni-toring in selected cases (95%, 21/22).
  2. Treat IIC patterns, as defined by American Clinical Neurophysiology Society criteria, in selected cases and when worsening trends are observed with lon-gitudinal EEG monitoring (100%, 20/20).
  3. Do not treat sporadic epileptiform discharges (100%, 24/24).

Sedation and Analgesia Statements

  1. The goals of analgesia and sedation during tem-perature control after CA are to provide comfort, to reduce shivering, and to prevent recall during NMB (100%, 21/21).
  2. Short-acting sedative and analgesic agents are preferred for patients in post-CA coma undergo-ing temperature control to reduce the duration of mechanical ventilation, time to awakening, and confounding of delayed prognostication (100%, 21/21).
  3. Propofol, remifentanil, and fentanyl are favored over midazolam and morphine infusions (85.7%, 18/21).
  4. Use NMB as needed during temperature control rather than as a continuous infusion. In addition, it is important to note that NMB may mask seizures in unmonitored patients (95.3%, 20/21).

Early Triage Statements 

  1. Early risk stratification is not intended as a tool for triage to withdraw life support and is not used for that purpose (90.5%, 19/21).
  2. Data that do not establish neurological risk strati-fication in the first 6 hours after CA include the patient’s age, duration of CPR, seizure activity, serum lactate level or pH, Glasgow motor subscore in patients who received NMB or sedation, pupil-lary function in patients who received atropine, and optic nerve sheath diameter (95.3%, 20/21).
  3. Validated illness severity scores may be used to optimize therapeutic interventions (88.2%, 15/17).

Cardiac Management Statements

  1. In ICUs where advanced cerebral monitoring is not in routine use, target an MAP >80 mm Hg unless there are clinical concerns or evidence of adverse consequences (82.6%, 19/23; same as in Brain Oxygenation, Perfusion, Edema, and ICP statements).
  2. In patients after CA, perform echocardiography as soon as possible to evaluate right and left ventricu-lar function, cardiac output, and inferior vena cava size to guide hemodynamic management and to search for correctable causes of the CA (95.7%, 22/23).
  3. Serial echocardiography can be helpful to guide ongoing hemodynamic management in patients after CA, at least until unsupported hemodynamic stability occurs (91.3%, 21/23).
  4. The choice of a target post-CA blood pressure incorporates the need to maintain adequate cere-bral perfusion during the period of maximal cere-bral edema and loss of cerebral autoregulation while accounting for the response of left ventricu-lar function to interventions as assessed by echo-cardiography (91.3%, 21/23).
  5. Individualize the choice of using inotropes, vaso-pressors, or fluids to treat post-CA hypotension and to target the likely cause(s) contributing to the shock and hemodynamic state (100%, 23/23).
  6. Serial measurements of central venous oxygen saturation, myocardial oxygen consumption, and lactate are helpful in monitoring the adequacy of systemic perfusion and the effectiveness of thera-pies used to treat shock (86.4%, 19/22).
  7. In patients with refractory hypoperfusion, evaluate early for mechanical circulatory support (includ-ing intra-aortic balloon pump, temporary right or left ventricular assist device, and extracorporeal membrane oxygenation) to improve end-organ perfusion. If mechanical circulatory support is not available, transfer to a center with these capabili-ties may be possible (95.7%, 22/23).
  8. Early coronary angiography in post-CA patients with no ST-segment elevation on the presenting ECG may still be of benefit by potentially salvag-ing myocardium and decreasing the incidence of systolic heart failure in survivors (95.7%, 22/23).

Pulmonary Statements 

  1. Lung-protective ventilation is a standard of care for most critically ill patients who are at risk for devel-oping ARDS, including those who remain coma-tose after CA (92%, 22/24).
  2. Once a reliable arterial oxygen saturation is avail-able after ROSC, titrate Fio2 to achieve an oxygen saturation (Spo2) of 92% to 98% (91.3%, 21/23).
  3. Do not titrate down Fio2 until reliable measure-ments of the oxygen saturation (Spo2) are available (91.3%, 21/23).
  4. Generally, adjust ventilation to target normal Paco2(35–45 mm Hg) after ROSC. There may be spe-cific patients for whom higher or lower CO2 may be appropriate. A higher Paco2 may be appropriate as long as pH can be maintained (>7.2). Alternatively, a slightly lower Paco2 within the normal range may be used to maintain a safe pH (>7.2) in patients with metabolic acidosis until acidosis can be other-wise treated (94.7%, 18/19).

Hematologic Management Statements  

  1. As for other critically ill patients, initiate RBCT when hemoglobin is <7 g/dL; however, higher transfusion thresholds (ie, <9 g/dL) may be indi-cated in patients with acute coronary disease (100%, 21/21).
  2. Individualize RBCTs to the clinical situation (81%, 17/21).
  3. Initiate DVT prophylaxis within 48 hours after admission unless there is contraindication (85.7%, 18/21).
  4. Low-molecular-weight heparin is the first choice for DVT prophylaxis (95.2%, 20/21).
  5. Low-dose heparin, dalteparin, or reduced doses of other low-molecular-weight heparins can be used in patients with kidney dysfunction. Monitoring of anti-Xa activity may be considered when low-molecular-weight heparin is used in this setting (90.5%, 19/21).

Digestive System Statements 

  1. Initiate EN as soon as possible after ICU admission (100%, 20/20).
  2. In patients with enteral intolerance or shock, start with trophic EN (rates of 10–20 mL/h) and adjust according to tolerance (91%, 19/21).
  3. Start parenteral nutrition when enteral feeding is not tolerated or is contraindicated after 5 to 7 days after CA (100%, 21/21).
  4. Give proton pump inhibitor or H2 blockers for stress ulcer prophylaxis per standard indications in the critically ill patient (90.5%, 19/21).
  5. In patients receiving EN, stress ulcer prophylaxis may not be necessary (90.5%, 19/21).

Infectious Disease Statements

  1. Empirical antibiotics may be used in patients who are treated with temperature management to a hypothermic target after CA to reduce the inci-dence of pneumonia (89.5%, 17/19).
  2. Do not use C-reactive protein and procalcitonin to guide antibiotic initiation or duration of therapy (85%, 17/20).

Endocrine and Fluids Management Statements 

  1. Volume management takes into consideration the cause of arrest, hemodynamic target chosen, and underlying organ dysfunction and is individualized to each patient (100%, 23/23).
  2. Balance the risk for cerebral edema with com-plications associated with hyperchloremia when choosing intravenous fluid after CA. The preferred choice in the setting of cerebral edema is normal saline, although balanced crystalloid solutions may minimize hyperchloremia and the potential for AKI when cerebral edema is not present (95.7%, 22/23).
  3. Do not use sodium bicarbonate routinely in patients after CA who have metabolic acidosis. Sodium bicarbonate may be considered in patients with severe metabolic acidosis (pH <7.2, bicarbonate <20) and AKI stage 2 or 3 (82.6%, 19/23).
  4. Consider RRT after CA for when life-threatening changes in fluid, electrolytes, and/or acid-base bal-ance exist and for conditions that can potentially be modified with RRT (100%, 23/23).
  5. Do not administer empirical corticosteroids to all patients after CA, although supplemental cortico-steroids may be useful to treat persistent shock in patients with proven or suspected adrenal sup-pression (91.3%, 21/23).
  6. Consider treatment of hyperglycemia with glucose targets of 81 to 180 mg/dL (100%, 19/19).

Treatment Protocols, Family Support, and Team-Based Care Statements

  1. Centers routinely providing post-CA care provide both physical comfort and emotional support to patients and families (95.7%, 22/23).
  2. Establish structured treatment protocols with input from multiple disciplines, including emergency, car-diology, critical care, neurology, nursing, and phar-macy, for an integrated multidisciplinary approach (91.3%, 21/23).
  3. Centers managing patients after CA should col-lect data and evaluate outcomes of care (95.7%, 22/23).
  4. Centers caring for patients after CA, particularly patients with neurological deficits, should offer specialized post-CA care, including the following:
    1. Cardiac catheterization team available 24 h/d and 7 d/wk,
    2. Temperature control available 24 h/d and 7 d/wk,
    3. Diagnostic testing available for prognostication,
    4. Intensive care team with specialty knowledge in post-CA care,
    5. Practitioners with expertise in interpretation of diagnostic testing for prognostication after CA,
    6. Patient and family support at discharge and provision of follow-up care after CA, and
    7. EEG monitoring capabilities (82.6%, 19/23).
  5. In patients after CA who remain unresponsive after ROSC, structured treatment protocols can be help-ful and defined in terms of bundles of care with a specific goal-directed approach (85.7%, 18/21).

Goals-of-Care Discussions and Family/Surrogate Support Statements 

  1. Include patients and/or surrogate decision makers as active participants in care and care decisions. These conversations should occur frequently and be clearly documented for other health care pro-fessionals who are not present during the conver-sations (96%, 22/23).
  2. Clinicians involved in goals-of-care decision- making may benefit from additional training to develop key skills and to address individual biases when facilitating these discussions (96%, 22/23).

Neurological Assessment Statements

  1. Assess neurological status frequently in patients who have an abnormal neurological examination after CA (90%, 18/20).
  2. Patients who are in a coma may benefit from a comprehensive neurological assessment. Table 4 gives the components of the neurological exami-nation when a patient is unresponsive (100%, 20/20).
  3. Evaluate quantitative pupillometry in patients who have an abnormal neurological examination and/or who are receiving significant doses of sedatives, analgesics, or paralytics (95%, 19/20).
  4. Changes in a neurological examination prompt timely evaluation of the need for further diagnostic tests to identify potentially treatable causes. The clinical treatment team has the ability to respond to monitoring changes by optimizing postresuscita-tion care (100%, 18/18).

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Critical Care Management of Patients After Cardiac Arrest

Authoring Organizations

American Heart Association

Neurocritical Care Society

Publication Month/Year

November 27, 2023

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Document Objectives

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Emergency care, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Rehabilitation

Diseases/Conditions (MeSH)

D003422 - Critical Care, D006323 - Heart Arrest

Keywords

cardiac arrest, critical care, heart attack

Source Citation

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society
Karen G. Hirsch, MDCo-Chair, Benjamin S. Abella, MD, MPhil, FAHA, Edilberto Amorim, MD, Mary Kay Bader, RN, MSN, FAHA, Jeffrey F. Barletta, PharmD, Katherine Berg, MD, Clifton W. Callaway, MD, PhD, FAHA, Hans Friberg, MD, PhD, Emily J. Gilmore, MD, David M. Greer, MD, FAHA, Karl B. Kern, MD, FAHA, Sarah Livesay, DNP, RN, Teresa L. May, DO, Robert W. Neumar, MD, PhD, FAHA, Jerry P. Nolan, MD, Mauro Oddo, MD, Mary Ann Peberdy, MD, FAHA, Samuel M. Poloyac, PharmD, PhD, David Seder, MD, FAHA, Fabio Silvio Taccone, MD, PhD, Anezi Uzendu, MD, Brian Walsh, PhD, RRT, Janice L. Zimmerman, MD, Romergryko G. Geocadin, MDCo-Chair, on behalf of the American Heart Association and Neurocritical Care Society