Focus on cardiac arrest

Intensive Care Medicine, Jun 2016

Alain Cariou, Antoine Vieillard-Baron, Anders Aneman

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Focus on cardiac arrest

Intensive Care Med Focus on cardiac arrest Alain Cariou 0 1 2 3 4 Antoine Vieillard‑Baron 4 6 7 Anders Aneman 4 5 0 AP‐HP, Medical Intensive Care Unit, Cochin Hospital , 27 Rue du Faubourg SaintJ‐acques, 75679 Paris Cedex 14 , France Full author information is available at the end of the article 1 Paris Descartes University , 15 2 AP‐HP, Medical Intensive Care Unit, Cochin Hospital , 27 Rue du Faubourg SaintJ‐acques, 75679 Paris Cedex 14 , France 3 INSERM U970 (Team 4) , Paris , France 4 Rue de l'Ecole de Médecine , 75270 Paris Cedex 06 , France 5 Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, University of New South Wales, South Western Sydney Clinical School, Ingham Institute for Applied Medical Research , New South Wales , Australia 6 INSERM U‐1018, CESP , Team 5 (EpReC , Renal and Cardiovascular Epidemiology), UVSQ , 94807 Villejuif , France 7 Section ThoraxV‐ascular Disease‐Abdomen‐Metab ‐ olism, Intensive Care Unit, University Hospital Ambroise Paré, Assistance Publique‐Hôpitaux de Paris , 92100 Boulogne‐Billancourt , France Outcome Cardiac arrest (CA) survival rates vary substantially, which may reflect differences in quality of the local chain of survival for both out-of-hospital and in-hospital cardiac arrest (OHCA and IHCA). A recent large, prospective, population-based registry conducted over 2  years in Paris, France, found a 7.5 % survival rate at discharge after OHCA [1] (Fig. 1), whereas a 10.8 % 30-day survival rate was reported from the Danish National Registry [2]. A recent analysis of the American Heart Association Get with the Guidelines-Resuscitation registry, including 358 hospitals between 2000 and 2009, documented a 18.8 % (IQR 14.5-22.6 %) median survival rate to hospital discharge following IHCA [3]. A similar survival rate (18.4  %) was reported by the UK National Cardiac Arrest Audit database [4]. Survival rates are widely variable in IHCA patients, depending on the location and circumstances, even for patients in intensive care units as illustrated by recent reports [5, 6]. The use of a prediction model in the emergency department could facilitate the identification of patients with a higher mortality risk [7] to guide preventive interventions. Post‑resuscitation care The importance of post-CA management is reflected by the substantial increase in clinical studies in recent years published in critical care journals. Health authorities and ethics committees ensure that the principles of ethical conduct of research involving human subjects are fulfilled, despite the time constraints and urgency inherent to CA and resuscitation, giving adequate opportunities for research [ 8 ]. The European Resuscitation Council (ERC) collaborated for the first time with the European Society of Intensive Care Medicine (ESICM) in 2015 to produce updated European post-resuscitation care guidelines [ 9, 10 ]. Changes in guidelines included a greater emphasis on the need for targeted temperature management (TTM) [11] that still seemed to be missing in almost half of CA patients according to pragmatic registry data [ 1 ]. The use of TTM at 33 °C was seriously challenged by the results of the landmark TTM Trial [ 12 ] and subsequent substudies. In a post hoc analysis of patients with moderate shock on admission after OHCA, TTM at 33  °C compared to 36 °C did not significantly influence 180-day mortality but was associated with increased levels of lactate and need for increased vasopressor support [ 13 ]. As it is difficult to discern which patients may further benefit from one or other temperature level, the ERC–ESICM 2015 guidelines acknowledge that there is now an option to target a temperature of 36 °C instead of the previously recommended 32–34 °C. The optimal time to start TTM is also challenged. Prehospital induction of hypothermia using cold fluids did not improve survival or neurological status among patients resuscitated from OHCA. Intraarrest induction of hypothermia did not confer any additional benefit as compared with hypothermia started at hospital arrival as judged by biological markers of inflammation or brain damage as well as clinical outcome in OHCA patients [ 14 ]. While these studies were performed irrespective of shockable or non-shockable initial cardiac rhythms, the importance of this issue remains debatable. The ERC–ESICM 2015 guidelines also highlighted the importance of early coronary angiogram and recommended that an early coronary angiogram (CAG) be performed in patients with ECG criteria for ST segment elevation myocardial infarction (STEMI), including left bundle branch block. Among patients without STEMI criteria, the best approach regarding coronary angiogram remains unclear. A TTM Trial post hoc analysis of patients without acute ST elevation found no difference in survival or neurological outcome between patients who did or did not receive an early CAG within 6  h of arrest, even after adjustment using a propen (...truncated)


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Alain Cariou, Antoine Vieillard-Baron, Anders Aneman. Focus on cardiac arrest, Intensive Care Medicine, 2016, pp. 1525-1527, Volume 42, Issue 10, DOI: 10.1007/s00134-016-4399-z