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The Post-cardiac Arrest Syndrome

  • J. P. Nolan
  • R. W. Neumar

Abstract

Survival rates following in- and out-of-hospital cardiac arrest remain disappointingly low [1, 2, 3] but there is good evidence that interventions applied after return of spontaneous circulation influence significantly the chances of survival with good neurological outcome [4]. Among those patients admitted to an intensive care unit (ICU) after cardiac arrest, approximately two thirds will not survive to be discharged from hospital [5, 6], but there is considerable variation in post-cardiac arrest treatment and patient outcome between institutions [6, 7]. The prolonged period of systemic ischemia during cardiac arrest and the subsequent reperfusion response that occurs after return of spontaneous circulation results in a complex combination of pathophysiological processes that have been termed recently the post-cardiac arrest syndrome [8]. The components of post-cardiac arrest syndrome comprise post-cardiac arrest brain injury, post-cardiac arrest myocardial dysfunction, systemic ischemia/ reperfusion response, and persistent precipitating pathology. A recent scientific statement from the International Liaison Committee on Resuscitation (ILCOR) and several other organizations provides comprehensive information about the epidemiology, pathophysiology, treatment, and prognostication of the post-cardiac arrest syndrome [8]. This chapter will highlight the main messages to come from this scientific statement.

Keywords

Cardiac Arrest Mean Arterial Pressure Cerebral Perfusion Pressure Therapeutic Hypothermia Spontaneous Circulation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Nichol G, Thomas E, Callaway CW, et al (2008) Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 300: 1423–1431CrossRefPubMedGoogle Scholar
  2. 2.
    Sandroni C, Nolan J, Cavallaro F, Antonelli M (2007) In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med 33: 237–245CrossRefPubMedGoogle Scholar
  3. 3.
    Nadkarni VM, Larkin GL, Peberdy MA, et al (2006) First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 295: 50–57CrossRefPubMedGoogle Scholar
  4. 4.
    Sunde K, Pytte M, Jacobsen D, et al (2007) Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73: 29–39CrossRefPubMedGoogle Scholar
  5. 5.
    Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K (2007) Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database. Anaesthesia 62: 1207–1216CrossRefPubMedGoogle Scholar
  6. 6.
    Carr BG, Kahn JM, Merchant RM, Kramer AA, Neumar RW (2009) Inter-hospital variability in post-cardiac arrest mortality. Resuscitation 80: 30–34CrossRefPubMedGoogle Scholar
  7. 7.
    Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA (2003) In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 56: 247–263CrossRefPubMedGoogle Scholar
  8. 8.
    Neumar R, Nolan JP, Adrie C, et al (2008) Post-Cardiac Arrest Syndrome: Epidemiology, pathophysiology, treatment and prognostication. Circulation 118: 2452–2483CrossRefPubMedGoogle Scholar
  9. 9.
    Laver S, Farrow C, Turner D, Nolan J (2004) Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 30: 2126–2128CrossRefPubMedGoogle Scholar
  10. 10.
    Neumar RW (2000) Molecular mechanisms of ischemic neuronal injury. Ann Emerg Med 36: 483–506PubMedGoogle Scholar
  11. 11.
    Wolfson SK Jr, Safar P, Reich H, et al (1992) Dynamic heterogeneity of cerebral hypoperfusion after prolonged cardiac arrest in dogs measured by the stable xenon/CT technique: a preliminary study. Resuscitation 23: 1–20CrossRefPubMedGoogle Scholar
  12. 12.
    Bottiger BW, Krumnikl JJ, Gass P, Schmitz B, Motsch J, Martin E (1997) The cerebral ‘noreflow’ phenomenon after cardiac arrest in rats — influence of low-flow reperfusion. Resuscitation 34: 79–87CrossRefPubMedGoogle Scholar
  13. 13.
    Sundgreen C, Larsen FS, Herzog TM, Knudsen GM, Boesgaard S, Aldershvile J (2001) Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke 32: 128–132PubMedGoogle Scholar
  14. 14.
    Zeiner A, Holzer M, Sterz F, et al (2001) Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome. Arch Intern Med 161: 2007–2012CrossRefPubMedGoogle Scholar
  15. 15.
    Krumholz A, Stern BJ, Weiss HD, (1988) Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus. Neurology 38: 401–405PubMedGoogle Scholar
  16. 16.
    Mullner M, Sterz F, Binder M, Schreiber W, Deimel A, Laggner AN (1997) Blood glucose concentration after cardiopulmonary resuscitation influences functional neurological recovery in human cardiac arrest survivors. J Cereb Blood Flow Metab 17: 430–436CrossRefPubMedGoogle Scholar
  17. 17.
    Laurent I, Monchi M, Chiche JD, et al (2002) Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 40: 2110–2116CrossRefPubMedGoogle Scholar
  18. 18.
    Adrie C, Adib-Conquy M, Laurent I, et al (2002) Successful cardiopulmonary resuscitation after cardiac arrest as a “sepsis-like” syndrome. Circulation 106: 562–568CrossRefPubMedGoogle Scholar
  19. 19.
    Adrie C, Laurent I, Monchi M, Cariou A, Dhainaou JF, Spaulding C (2004) Postresuscitation disease after cardiac arrest: a sepsis-like syndrome? Curr Opin Crit Care 10: 208–212CrossRefPubMedGoogle Scholar
  20. 20.
    Adrie C, Monchi M, Laurent I, et al (2005) Coagulopathy after successful cardiopulmonary resuscitation following cardiac arrest: implication of the protein C anticoagulant pathway. J Am Coll Cardiol 46: 21–28CrossRefPubMedGoogle Scholar
  21. 21.
    Spaulding CM, Joly LM, Rosenberg A, et al (1997) Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 336: 1629–1633CrossRefPubMedGoogle Scholar
  22. 22.
    Kurkciyan I, Meron G, Sterz F, et al (2000) Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med 160: 1529–1535CrossRefPubMedGoogle Scholar
  23. 23.
    Nolan JP, Soar J (2008) Post resuscitation care — time for a care bundle? Resuscitation 76: 161–162CrossRefPubMedGoogle Scholar
  24. 24.
    Buunk G, van der Hoeven JG, Meinders AE (1997) Cerebrovascular reactivity in comatose patients resuscitated from a cardiac arrest. Stroke 28: 1569–1573PubMedGoogle Scholar
  25. 25.
    Liu Y, Rosenthal RE, Haywood Y, Miljkovic-Lolic M, Vanderhoek JY, Fiskum G (1998) Normoxic ventilation after cardiac arrest reduces oxidation of brain lipids and improves neurological outcome. Stroke 29: 1679–1686PubMedGoogle Scholar
  26. 26.
    Balan IS, Fiskum G, Hazelton J, Cotto-Cumba C, Rosenthal RE, (2006) Oximetry-guided reoxygenation improves neurological outcome after experimental cardiac arrest. Stroke 37: 3008–3013CrossRefPubMedGoogle Scholar
  27. 27.
    O’Driscoll BR, Howard LS, Davison AG (2008) Guideline for emergency oxygen use in adult patients. Thorax 63: vi1–vi73CrossRefPubMedGoogle Scholar
  28. 28.
    Zipes DP, Wellens HJ (1998) Sudden cardiac death. Circulation 98: 2334–2351PubMedGoogle Scholar
  29. 29.
    Garot P, Lefevre T, Eltchaninoff H, et al (2007) Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation myocardial infarction. Circulation 115: 1354–1362CrossRefPubMedGoogle Scholar
  30. 30.
    Pene F, Hyvernat H, Mallet V, et al (2005) Prognostic value of relative adrenal insufficiency after out-of-hospital cardiac arrest. Intensive Care Med 31: 627–633CrossRefPubMedGoogle Scholar
  31. 31.
    Rivers E, Nguyen B, Havstad S, et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345: 1368–1377CrossRefPubMedGoogle Scholar
  32. 32.
    Zandbergen EG, Hijdra A, Koelman JH, et al (2006) Prediction of poor outcome within the first 3 days of postanoxic coma. Neurology 66: 62–68CrossRefPubMedGoogle Scholar
  33. 33.
    van den Berghe G, Wouters P, Weekers F, et al (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345: 1359–1367CrossRefPubMedGoogle Scholar
  34. 34.
    Oksanen T, Skrifvars MB, Varpula T, et al (2007) Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med 33: 2093–2100CrossRefPubMedGoogle Scholar
  35. 35.
    Losert H, Sterz F, Roine RO, et al (2008) Strict normoglycaemic blood glucose levels in the therapeutic management of patients within 12h after cardiac arrest might not be necessary. Resuscitation 76: 214–220CrossRefPubMedGoogle Scholar
  36. 36.
    Van den Berghe G, Wilmer A, Hermans G, et al (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354: 449–461CrossRefPubMedGoogle Scholar
  37. 37.
    Nolan JP, Morley PT, Vanden Hoek TL, Hickey RW (2003) Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement Life support Task Force of the International Liaison committee on Resuscitation. Resuscitation 57: 231–235CrossRefPubMedGoogle Scholar
  38. 38.
    Soar J, Nolan JP (2007) Mild hypothermia for post cardiac arrest syndrome. BMJ 335: 459–460CrossRefPubMedGoogle Scholar
  39. 39.
    Hypothermia After Cardiac Arrest Study Group (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346: 549–556CrossRefGoogle Scholar
  40. 40.
    Bernard SA, Gray TW, Buist MD, et al (2002) Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346: 557–563CrossRefPubMedGoogle Scholar
  41. 41.
    Arrich J (2007) Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med 35: 1041–1047CrossRefPubMedGoogle Scholar
  42. 42.
    Wolff B, Machill K, Schumacher D, Schulzki I, Werner D (2009) Early achievement of mild therapeutic hypothermia and the neurologic outcome after cardiac arrest. Int J Cardiol (in press)Google Scholar
  43. 43.
    Kim F, Olsufka M, Longstreth WT Jr, et al (2007) Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation 115: 3064–3070CrossRefPubMedGoogle Scholar
  44. 44.
    Merchant RM, Abella BS, Peberdy MA, et al (2006) Therapeutic hypothermia after cardiac arrest: Unintentional overcooling is common using ice packs and conventional cooling blankets. Crit Care Med 34: S490–S494CrossRefPubMedGoogle Scholar
  45. 45.
    Hickey RW, Kochanek PM, Ferimer H, Alexander HL, Garman RH, Graham SH, (2003) Induced hyperthermia exacerbates neurologic neuronal histologic damage after asphyxial cardiac arrest in rats. Crit Care Med 31: 531–535CrossRefPubMedGoogle Scholar
  46. 46.
    Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S (2006) Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 67: 203–210CrossRefPubMedGoogle Scholar
  47. 47.
    Booth CM, Boone RH, Tomlinson G, Detsky AS (2004) Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA 291: 870–879CrossRefPubMedGoogle Scholar
  48. 48.
    Zandbergen EG, de Haan RJ, Stoutenbeek CP, Koelman JH, Hijdra A (1998) Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet 352: 1808–1812CrossRefPubMedGoogle Scholar
  49. 49.
    Peberdy MA, Kaye W, Ornato JP, et al (2003) Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 58: 297–308CrossRefPubMedGoogle Scholar
  50. 50.
    Adrie C, Haouache H, Saleh M, et al (2008) An underrecognized source of organ donors: patients with brain death after successfully resuscitated cardiac arrest. Intensive Care Med 34: 132–137CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2009

Authors and Affiliations

  • J. P. Nolan
    • 1
  • R. W. Neumar
    • 2
  1. 1.Department of Anesthesiology and Intensive CareRoyal United HospitalBathUK
  2. 2.Department of Emergency Medicine University of Pennsylvania School of MedicineHospital of the University of PennsylvaniaPhiladelphiaUSA

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