Post-resuscitation care #LIVES2017

How we best manage patients after cardiac arrest is an area full of controversy. This session was designed to cover aspects of uncertainty surrounding this area with presentations from Alain Cariou on who should have early coronary angiography, Gavin Perkins on oxygenation and ventilation and Alain Combes on ECMO for refractory cardiogenic shock:

Three take home messages for me:

  1. Currently no indication for coronary reperfusion in non-STEMI. Need to consider on case-by-case basis locally and await evidence from multiple ongoing RCTs
  2. Need to pay close attention to O2 and CO2 in acute period post-arrest. Avoid hyperoxia and (most interestingly) avoid hyPOcapnia.
  3. ECMO-CPR shows promise in the management of cardiogenic shock post-arrest but needs large RCT data

Alain Cariou: Indications for early coronary reperfusion

Results from the PROCAT registry study from Paris is pretty clear that we should ideally perform early coronary angiogram in all survivors of cardiac arrest. However no RCT data to prove improved outcomes in those with non-STEMI so question still remains unclear

All patients with OHCA at his centre get immediate PCI – very different in UK due to lack of RCT data – hence reticence from cardiologists in UK

And whilst this seems wrong, it may not be such a difficult approach to justify given that a post-hoc analysis of TTM trial showed NO benefit from PCI for all-comers.

However, we may have some clear RCT data very soon…. The DISCO trial (great name) in Finland is a RCT randomised to immediate cath lab or ICU then decision. Similar trials in France (EMERGE) and US (PEARL) as well as trials in Germany/Holland are asking similar questions so we should soon have more data to guide our decision making in this period.

Still data from the PROCAT-II trial shows that there is a culprit lesion in 1/3 pts even without STE. We therefore need more data to help select those patients most at risk or identify better those likely to survive with preserved neurological function

So…can we predict neurological outcome better? CAHP score is one option he uses locally. Need more work on this though to help guide future management.

Great talk by Alain Cariou overall – was asked a question about in-hospital arrest? His answer is that it is a different population  and needs more research to be conducted.

Prof Gavin Perkins on Oxygenation and Ventilation post-ROSC

First question is what is the optimal level of oxygenation during/immediately after CPR? Nice review on this here

There is a growing awareness that like many things in ICM (e.g. fluids)  less may be more when it comes to oxygenation in the critically unwell. Data from animal trials suggest that outcomes are likely to be worse with higher FiO2 post-ROSC.

Arterial hyperoxia is also independently associated with higher in-hospital mortality compared to either hypoxia or normoxia

However, this is a difficult effect to isolate due to the fact that unmeasured confounders (e.g.severity of illness) can contribute in registry studies of FIO2 & outcome. For example, those patients who are more unwell tend to need higher FiO2

There is potentially a signal of increased heart damage too with higher oygenation although this was not reproduced in a larger 2017 trial. 

FiO2 1.0 assoc with higher biomarkers of brain injury e.g. enolase but in a small study

So pulling this together clinically – what shouldcurrent guidance in absence of large RCT

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What about the role of CO2 post-arrest? 

Hypocapnia seems to be independently assoc with worse outcomes and hypercapnia protective – interesting result that goes against much of what we teach in managing brain injury on ICU – is cerebral vasodilation with slightly higher ICP better than lower CO2 and cerebral vasoconstriction.

Big take home for me: AVOID HYPEROXIA and HYPOCAPNIA post-arrest

Alain Combes on ECMO in cardiogenic shock

CPR duration is key still in determining outcomes – 

There has been a series of papers showing signal of improved outcome using ECMO-CPR approach – mainly from Japan where they have a very efficient resuscitation network

Data from a 2016 systematic review on ECMO-CPR showed a 27% survival compared to 15% with routine care. However, this survival benefit drops when you isolate those patients left with good neurlogical outcomes (18% v 7%).

So, what are Alain Combes’ local guidelines for E-CPR?

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What is best strategy for E-CPR? E-CPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors.

Guess what though? Current evidence needs to be confirmed by a large RCT….. 😉 Luckily a few currently in the pipeline…

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Overall a really enjoyable session and thanks to the ESICM and the speakers!