Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

Higher versus lower mean arterial blood pressure after cardiac arrest and resuscitation (MAP-CARE): A protocol for a randomized clinical trial

BACKGROUND

In patients resuscitated after cardiac arrest, a higher mean arterial pressure (MAP) may increase cerebral perfusion and attenuate hypoxic brain injury. Here we present the protocol of the mean arterial pressure after cardiac arrest and resuscitation (MAP-CARE) trial aiming to investigate the influence of MAP targets on patient outcomes.

METHODS

MAP-CARE is one component of the Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) 2 x 2 x 2 factorial randomized trial. The MAP-CARE trial is an international, multicenter, parallel-group, investigator-initiated, superiority trial designed to test the hypothesis that targeting a higher (>85 mmHg) (intervention) versus a lower (>65 mmHg) (comparator) MAP after resuscitation from cardiac arrest reduces 6-month mortality (primary outcome). Trial participants are adults with sustained return of spontaneous circulation who are comatose following resuscitation from out-of-hospital cardiac arrest. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to allocation group. The sample size of 3500 participants provides 90% power with an alpha of 0.05 to detect a 5.6 absolute risk reduction in 6-month mortality, assuming a mortality of 60% in the control group. Secondary outcomes will be poor functional outcome 6 months after randomization, patient-reported overall health 6 months after randomization, and the proportion of participants with predefined severe adverse events.

CONCLUSION

The MAP-CARE trial will investigate if targeting a higher MAP compared to a lower MAP during intensive care of adults who are comatose following resuscitation from out-of-hospital cardiac arrest reduces 6-month mortality.

Oxygen and carbon dioxide targets after cardiac arrest: an updated systematic review

AIM

To perform an updated systematic review and meta-analysis of oxygen and carbon dioxide targets in patients with sustained return of spontaneous circulation after cardiac arrest.

METHODS

Searches were conducted in MEDLINE, Embase, and Evidence-Based Medicine Reviews from August 2019 to March 2025 for randomised trials comparing specific oxygen or carbon dioxide targets in post-cardiac arrest patients. Two investigators independently reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. The certainty of evidence was evaluated using GRADE methodology.

RESULTS

Fifteen manuscripts from 12 trials were included. All trials were limited to adult patients, primarily including out-of-hospital cardiac arrests. Five trials evaluated oxygen targets in the prehospital setting, while six evaluated oxygen targets and three evaluated carbon dioxide targets in the intensive care unit setting. Risk of bias was assessed as moderate for most outcomes. Meta-analyses found no differences in survival or favourable functional outcomes when comparing restrictive to liberal oxygen targets in either setting. There was also no difference in outcomes when comparing mild hypercapnia to normocapnia. The certainty of evidence was rated as low to moderate.

CONCLUSIONS

Among patients resuscitated from cardiac arrest, neither restrictive oxygen targets nor mild hypercapnia, compared to conventional targets, improved survival or functional outcomes.

Impact of Hypothermic Temperature Control on Plasma and Soft Tissue Pharmacokinetics of Penicillin/Beta-Lactamase Inhibitor Combinations in Patients Resuscitated After Cardiac Arrest

BACKGROUND AND OBJECTIVES

Penicillin/beta-lactamase inhibitors are often used to treat aspiration pneumonia in patients resuscitated after cardiac arrest (CA). The impact of hypothermic temperature control on the pharmacokinetics of amoxicillin/clavulanate (AMO/CLAV) and ampicillin/sulbactam (AMP/SULB) has not been studied. Our objective was to evaluate the effects of hypothermic temperature control on the plasma and soft tissue pharmacokinetics of AMO/CLAV and AMP/SULB, including pulmonary concentrations of AMP/SULB, in patients resuscitated after CA.

METHODS

This prospective clinical study involved ten adult patients after CA receiving either AMO/CLAV 2 g/0.2 g or AMP/SULB 2 g/1 g intravenously every 8 h. Patients underwent hypothermic temperature control (33 ± 1 °C) for 24 h, followed by normothermia. Plasma, urine, muscle, and subcutaneous pharmacokinetics were measured and plasma protein-binding assessed for each subject. Microdialysis determined unbound drug concentrations in soft tissues. The pulmonary concentration of AMP/SULB was analyzed in the epithelial lining fluid.

RESULTS

No significant differences in plasma pharmacokinetics or renal excretion of AMO/CLAV and AMP/SULB were observed between the two temperature conditions. Soft tissue concentrations showed no consistent trend. Pharmacokinetic/pharmacodynamic targets (time that the unbound plasma concentrations were above the minimal inhibitory concentration [MIC] for MIC up to 8 mg/L) were met but not for 16 mg/L. Pulmonary concentrations of AMP/SULB in the epithelial lining fluid showed no clear trend.

CONCLUSION

This study indicates that hypothermic temperature control does not significantly affect plasma concentrations, soft tissue concentrations, or renal excretion of AMO/CLAV and AMP/SULB in patients resuscitated after CA. However, pulmonary concentrations of AMP/SULB exhibited interindividual variability.

Emergency medicine updates: Cardiac arrest airway management

INTRODUCTION

Cardiac arrest is the loss of systemic circulation. The approach to airway management is an important component of the resuscitation of patients in cardiac arrest.

OBJECTIVE

This paper evaluates key evidence-based updates concerning airway management in cardiac arrest.

DISCUSSION

Management of cardiac arrest focuses on cardiopulmonary resuscitation (CPR), including high-quality chest compressions and ventilation. Resuscitation should prioritize circulation with high-quality compressions, but as the resuscitation continues, airway management is necessary to provide ventilation. During initial CPR efforts, a compression to ventilation ratio of 30:2 is recommended. Bag-valve-mask (BVM) ventilation is an effective means of ventilation during CPR efforts, though providers should ensure appropriate mask seal with a two-person BVM strategy (one person holding the mask and one person ventilating) if possible. Breaths should be provided over less than 1 s with enough tidal volume to cause chest rise. Advanced airways include a supraglottic airway (SGA) or endotracheal tube via endotracheal intubation (ETI). If an advanced airway is present, one asynchronous ventilation should be provided every 8-10 s. An advanced airway may be considered with an asphyxial cause of arrest, those with prolonged arrest or transport, and cases managed with limited numbers of experienced personnel, though compressions must not be interrupted for placement of an advanced airway. An SGA is a viable option for an advanced airway. In settings with high ETI success rate, ETI may be performed, but in other settings SGA is recommended. If performing ETI, video laryngoscopy is associated with an improved view of the glottis and higher first pass success compared to direct laryngoscopy. Cricoid pressure is not recommended. Confirmation of ETI is necessary. Following ETI and return of spontaneous circulation, a lung protective strategy of ventilation is recommended while avoiding hypoxia.

CONCLUSIONS

An understanding of literature updates regarding airway management can improve the ED care of patients in cardiac arrest.

Timing of neuroprognostication in the ICU

PURPOSE OF REVIEW

Neuroprognostication after acute brain injury (ABI) is complex. In this review, we examine the threats to accurate neuroprognostication, discuss strategies to mitigate the self-fulfilling prophecy, and how to approach the indeterminate prognosis.

RECENT FINDINGS

The goal of neuroprognostication is to provide a timely and accurate prediction of a patient's neurologic outcome so treatment can proceed in accordance with a patient's values and preferences. Neuroprognostication should be delayed until at least 72 h after injury and/or only when the necessary prognostic data is available to avoid early withdraw life-sustaining treatment on patients who may otherwise survive with a good outcome. Clinicians should be aware of the limitations of available predictors and prognostic models, the role of flawed heuristics and the self-fulfilling prophecy, and the influence of surrogate decision-maker bias on end-of-life decisions.

SUMMARY

The approach to neuroprognostication after ABI should be systematic, use highly reliable multimodal data, and involve experts to minimize the risk of erroneous prediction and perpetuating the self-fulfilling prophecy. Even when such standards are rigorously upheld, the prognosis may be indeterminate. In such cases, clinicians should engage in shared decision-making with surrogates and consider the use of a time-limited trial.

Survival rates with favorable neurological outcomes after in-hospital and out-of-hospital cardiac arrest: A prospective cohort study

OBJECTIVES

To evaluate the survival rates with favorable neurological outcomes among patients who experienced in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA).

DESIGN

This prospective cohort study assessed 554 adult patients with IHCA or OHCA referred to Hamad General Hospital, Qatar, between February 2015 and November 2021. Neurologic outcomes were measured using the Cerebral Performance Category (CPC) score. Survival rate and neurologic status were re-evaluated at 28 days, hospital discharge, and one year after cardiac arrest (CA).

FINDINGS

For all participants, the hospital discharge and one-year survival rates with a favorable neurological outcome (CPC ≤ 2) were 18.5 % and 19.5 %, respectively. Specifically, among patients with IHCA, the rates were 20.5 % and 19 %, while in patients with OHCA, the rates were 16.4 % and 19.9 %, respectively. Multivariate regression analysis indicated that factors male sex (OR: 2.129, 95 % CI: 1.168-3.881, P = 0.014), initial shockable rhythm (OR: 1.691, 95 % CI: 1.024-2.788, P = 0.041), and the use of ECPR (OR: 1.944, 95 % CI: 1.178-3.209, P = 0.009) were associated with increased likelihood of survival with favorable neurological outcomes at 28 days. Conversely, older age, presence of comorbidities, infection, higher APACHE II score, longer hospital stays, and undergoing tracheostomy were linked to decreased chances of survival with favorable neurological outcomes at different time points.

CONCLUSION

Survival with good neurological outcomes after OHCA was 20.3 %, 16.4 %, and 19.9 % at 28 days, hospital discharge, and one year, respectively. Among patients with IHCA, survival with good neurological outcomes was 20.5 %, 20.5 %, and 19 % at 28 days, hospital discharge, and one year, respectively.

IMPLICATIONS FOR CLINICAL PRACTICE

Care of CA patients in a cardiac arrest center is associated with improved long-term survival with favorable neurological outcomes. Prioritizing early intervention for shockable rhythms and utilizing ECPR where appropriate could enhance patient prognosis.

Emergency medicine updates: Managing the patient with return of spontaneous circulation

INTRODUCTION

Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition.

OBJECTIVE

This paper provides evidence-based updates concerning the management of the post-ROSC patient.

DISCUSSION

The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92-98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35-55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients require emergent coronary angiography. However, if the patient has ST-segment elevation on ECG following ROSC, emergent angiography and catheterization is recommended. This should also be considered if the patient had an initial history concerning for acute coronary syndrome or a presenting arrhythmia of ventricular fibrillation or pulseless ventricular tachycardia. TTM at 32-34° C does not appear to demonstrate improved outcomes compared with targeted normothermia, but fever should be avoided.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients post-ROSC.

Prolonged Monitoring of Brain Electrical Activity in the Intensive Care Unit

Electroencephalography (EEG) has been used to assess brain electrical activity for over a century. More recently, technological advancements allowed EEG to be a widely available and powerful tool in the intensive care unit (ICU), where patients at risk for cerebral dysfunction and brain injury can be monitored in a continuous, real-time manner. In the last 2 decades, several organizations established guidelines for continuous EEG monitoring in the ICU, defining critical care EEG terminology and technical standards for technicians, machines, and electroencephalographers. This article provides an overview of the current role of continuous EEG monitoring in the ICU.

Cardiovascular complications in chronic active Epstein-Barr virus disease: a case report and literature review

Background

Cardiovascular involvement is a rare but severe complication of Epstein-Barr virus (EBV) infections. Patients with chronic active EBV (CAEBV) are at increased risk of developing cardiovascular complications and have a poor prognosis. Here, we report the rare case of a pediatric patient with CAEBV and EBV- hemophagocytic lymphohistiocytosis (HLH) complicated with a giant coronary artery aneurysm (CAA) and thrombosis, a giant Valsalva sinus aneurysm, and ascending aorta dilation seven years after the disease onset.

Case presentation

A previously healthy 3-year-old girl was initially misdiagnosed as presenting incomplete Kawasaki disease complicated by coronary artery lesions (CALs) for which she received intravenous immunoglobulin and aspirin therapy. Subsequently, she was transferred to our hospital, where we diagnosed her as having a primary EBV infection. After acyclovir therapy, her clinical symptoms resolved with negative EBV-DNA, and she was discharged home with aspirin treatment for the remaining CALs. However, she did not have regular follow-ups after that. Seven years later, the 10-year-old girl developed a prolonged fever and fatigue, and she was diagnosed as presenting CAEBV and EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH) due to the presence of a high EBV-DNA load, prolonged fever, splenomegaly, bicytopenia, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis, low NK-cell activity, and increased levels of ferritin and soluble CD25. The echocardiography images showed giant left and right coronary artery aneurysms, a giant Valsalva sinus aneurysm, and ascending aorta dilation. Her parents agreed to a therapy with intravenous immunoglobulin, methylprednisolone, antiplatelet, and anticoagulant, but not to the standard therapy of EBV-HLH. However, the cardiovascular complications, including CAAs and thrombosis, Valsalva sinus aneurysm, and aorta lesions, did not resolve. Three weeks later, the patient was finally discharged home asymptomatic. Unfortunately, one month after discharge, the fever recurred the girl. The guardian had refused treatment and took the patient home due to economic difficulties. During our subsequent follow-up visit, the girl subsequently passed away.

Conclusions

We reported the case of a pediatric patient with EBV infection who developed rare and fatal cardiovascular complications (CAAs and thrombosis, Valsalva sinus aneurysm, and aortic lesions) seven years after the onset of the infection. Clinicians should be aware of these complications during the long-term follow-up of patients with EBV infection, especially in patients with CAEBV and/or EBV-HLH.

Plasma phosphorylated tau (p-tau231) and total tau (t-tau) as prognostic markers of neurological outcome after cardiac arrest - a multicentre study

PURPOSE

We studied the promising Alzheimer biomarker plasma tau phosphorylated at threonine 231 (p-tau231) in a cohort of cardiac arrest patients who survived to intensive care to predict long-term neurological outcomes. We also compared it to total tau (t-tau), which has demonstrated predictive abilities of neurological outcome post-cardiac arrest.

METHODS

This observational multicentre cohort study included 425 patients admitted to intensive care after cardiac arrest. Plasma p-tau231 was retrospectively analysed at admission, 12 and 48 h after cardiac arrest. The association of the Cerebral Performance Category (CPC) with p-tau231 was analysed with a one-way analysis of variance (ANOVA). CPC was modelled using multivariate ordinal logistic regression, and the biomarkers' prognostic performance was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

Increasing p-tau231 levels were significantly associated with worse CPC (p < 0.001). P-tau231 showed moderate prognostic abilities (AUC: 0.69 on admission, 0.72 at 12 h, and 0.71 at 48 h) for all patients but did not improve neurological prognostication after adjusting for clinical covariates. Elevated levels of t-tau were significantly associated with a worse outcome at all time points (p < 0.001). T-tau significantly improved neurological prognosis at 48 h after adjusting for covariates (AUC: 0.95, 95 % CI 0.93-0.98, p < 0.001) compared to the clinical covariate reference model (AUC: 0.88, 95 % CI 0.84-0.93).

CONCLUSIONS

Although p-tau231 showed moderate neurological prognostic ability, t-tau was a stronger predictor, particularly at 48 h, even after adjusting for clinical covariates.

Effect of chest compressions in addition to extracorporeal life support on carotid flow in an experimental model of refractory cardiac arrest in pigs

Background

Extracorporeal life support (ECLS) provides organ perfusion in refractory cardiac arrest but during the initiation of ECLS mean arterial pressure (MAP) and carotid flow may be suboptimal due to hypotension and/or insufficient flow. We hypothesized that cardiopulmonary resuscitation (CPR) in addition to ECLS may increase carotid flow and MAP compared to ECLS alone.

Methods

Observational pilot study comparing hemodynamic parameters before and after CPR cessation in pigs supported by ECLS for experimental refractory cardiac arrest. Pigs were anesthetized, ventricular fibrillation was induced for 3 min, automated CPR performed for 30 min, ECLS was initiated then CPR stopped.Variables averaged over 3 s were compared between the last 3 s of CPR + ECLS and 3, 6, 30 s, and 5 and 10 min of ECLS alone. Data are expressed as medians (25-75 interquartile range) and compared using paired samples Wilcoxon test.

Results

Nine pigs were included, ECLS was initiated at 2.7 (2.3-2.8) L/min. MAP during CPR + ECLS was 56(53.0-59.2) mmHg, versus 50(45-57)mmHg, 52(46-59)mmHg, 61(50-63)mmHg, 57 (54-66)mmHg, 54 (47-58)mmHg of ECLS alone, p = 0.50, 0.61, 0.70, 0.44, 0.73 respectively. Carotid flow was 113(78-119) ml/min during CPR + ECLS versus 99(79-110)ml/min, 100(81-110)ml/min, 96(60-122)ml/min, 118 (101-130)ml/min, 124 (110-141)ml/min, p = 0.41, 0.52, 0.73, 0.33, 0.20 respectively. When ECLS was initiated at lower flow, 1.5 L/min (one pig), MAP decreased from 59 to 45 mmHg, and carotid flow from 78.2 to 32.5 ml/min after 3 s of ECLS alone.

Conclusion

Stopping CPR after effective ECLS initiation does not decrease MAP or carotid flow. Future studies may evaluate augmenting low flow ECLS with CPR.

Using machine learning to predict neurologic injury in venovenous extracorporeal membrane oxygenation recipients: An ELSO Registry analysis

Background

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is associated with acute brain injury (ABI), including central nervous system (CNS) ischemia (defined as ischemic stroke or hypoxic-ischemic brain injury [HIBI]) and intracranial hemorrhage (ICH). Data on prediction models for neurologic outcomes in VV-ECMO are limited.

Methods

We analyzed adult (age ≥18 years) VV-ECMO patients in the Extracorporeal Life Support Organization (ELSO) Registry (2009-2021) from 676 centers. ABI was defined as CNS ischemia, ICH, brain death, and seizures. Data on 67 variables were extracted, including clinical characteristics and pre-ECMO/on-ECMO variables. Random forest, CatBoost, LightGBM, and XGBoost machine learning (ML) algorithms (10-fold leave-one-out cross-validation) were used to predict ABI. Feature importance scores were used to pinpoint the most important variables for predicting ABI.

Results

Of 37,473 VV-ECMO patients (median age, 48.1 years; 63% male), 2644 (7.1%) experienced ABI, including 610 (2%) with CNS ischemia and 1591 (4%) with ICH. The areas under the receiver operating characteristic curve for predicting ABI, CNS ischemia, and ICH were 0.70, 0.68, and 0.70, respectively. The accuracy, positive predictive value, and negative predictive value for ABI were 85%, 19%, and 95%, respectively. ML identified higher center volume, pre-ECMO cardiac arrest, higher ECMO pump flow, and elevated on-ECMO serum lactate level as the most important risk factors for ABI and its subtypes.

Conclusions

This is the largest study of VV-ECMO patients to use ML to predict ABI reported to date. Performance was suboptimal, likely due to lack of standardization of neuromonitoring/imaging protocols and data granularity in the ELSO Registry. Standardized neurologic monitoring and imaging are needed across ELSO centers to detect the true prevalence of ABI.

Microbiological features of drowning-associated pneumonia: a systematic review and meta-analysis

BACKGROUND

Drowning-associated pneumonia (DAP) is frequent in drowned patients, and possibly increases mortality. A better understanding of the microorganisms causing DAP could improve the adequacy of empirical antimicrobial therapy. We aimed to describe the pooled prevalence of DAP, the microorganisms involved, and the impact of DAP on drowned patients.

METHODS

Systematic review and meta-analysis of studies published between 01/2000 and 07/2023 reporting on DAP occurrence and microorganisms involved.

RESULTS

Of 309 unique articles screened, 6 were included, involving 688 patients. All were retrospective cohort studies, with a number of patients ranging from 37 to 270. Studies were conducted in Europe (France N = 3 and Netherland N = 1), United States of America (N = 1) and French West Indies (N = 1). Mortality ranged between 18 to 81%. The pooled prevalence of DAP was 39% (95%CI 29-48), similarly following freshwater (pooled prevalence 44%, 95%CI 36-52) or seawater drowning (pooled prevalence 42%, 95%CI 32-53). DAP did not significantly impact mortality (pooled odds ratio 1.43, 95%CI 0.56-3.67) but this estimation was based on two studies only. Respiratory samplings isolated 171 microorganisms, mostly Gram negative (98/171, 57%) and mainly Aeromonas sp. (20/171, 12%). Gram positive microorganisms represented 38/171 (22%) isolates, mainly Staphylococcus aureus (21/171, 12%). Water salinity levels had a limited impact on the distribution of microorganisms, except for Aeromonas sp. who were exclusively found following freshwater drowning (19/106, 18%) and never following seawater drowning (0%) (p = 0.001). No studies reported multidrug-resistant organisms but nearly 30% of the isolated microorganisms were resistant to amoxicillin-clavulanate, the drug that was the most commonly prescribed empirically for DAP.

CONCLUSIONS

DAP are commonly caused by Gram-negative bacteria, especially Aeromonas sp. which is exclusively isolated following freshwater drowning. Empirical antimicrobial therapy should consider covering them, noting than amoxicillin-clavulanate may be inadequate in about one-third of the cases. The impact of DAP on patients' outcome is still unclear.