Critical Care Management of Patients After Cardiac Arrest

Publication Date: November 28, 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)

Overview

Title

Critical Care Management of Patients After Cardiac Arrest

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