Use of a Standardized Treatment Protocol for Post-cardiac Resuscitation Care

  • M. A. Kuiper
  • P. E. Spronk
  • M. J. Schultz


For a long time, the outcome of patients after out-of-hospital cardiac arrest has been extremely poor, with only 5–10 % of survivors having a good neurological outcome. In recent years, several studies have demonstrated an increase in survival of cardiac arrest patients admitted to the intensive care unit (ICU), often with more than 60 % having good neurological outcome [1, 2, 3, 4, 5, 6]. Since the introduction of cardiopulmonary resuscitation (CPR) in the early 1960s by Safar and McMahon (mouth-to-mouth respiration) [7] and Kouwenhoven et al. (closed chest-compression) [8], the emphasis in resuscitation medicine has been on the treatment of cardiac arrest until return of spontaneous circulation, with manual CPR and early defibrillation of convertible cardiac rhythms being the two most important items. The general consensus was that improvement of outcome of cardiac arrest patients would solely lie in shortening the period of circulatory standstill, thus minimizing the, mainly neurological, damage. Having restored the circulation, treating physicians “could only wait and see what the outcome would be”. However, alongside the processes of recovery and compensation, a pathological state may develop with associated organ failure — the so-called post-resuscitation syndrome. Physicians should be aware of this condition and actively treat its complications to improve the condition of the patient and to increase the chance of a good neurological outcome after cardiac arrest. Induced mild hypothermia is an important factor in this aspect and has become an established treatment for the post-resuscitation patient. However, induced mild hypothermia is not the sole treatment modality that should be used.


Cardiac Arrest Mean Arterial Blood Pressure Therapeutic Hypothermia Mild Hypothermia Advanced Life Support 
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.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Oddo M, Schaller MD, Feihl F, Ribordy V, Liaudet L (2006) From evidence to clinical practice: effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest. Crit Care Med 34: 1865–1873PubMedGoogle Scholar
  2. 2.
    Al-Senani FM, Graffagnino C, Grotta JC, et al (2004) A prospective, multicenter pilot study to evaluate the feasibility and safety of using the CoolGard System and Icy catheter following cardiac arrest. Resuscitation 62: 143–150CrossRefPubMedGoogle Scholar
  3. 3.
    Busch M, Soreide E, Lossius HM, Lexow K, Dickstein K (2006) Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors. Acta Anaesthesiol Scand 50: 1277–1283CrossRefPubMedGoogle 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.
    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
  6. 6.
    Belliard G, Catez E, Charron C, et al (2007) Efficacy of therapeutic hypothermia after out-ofhospital cardiac arrest due to ventricular fibrillation. Resuscitation 75: 252–259CrossRefPubMedGoogle Scholar
  7. 7.
    Safar P, McMahon M (1958) Mouth-to-airway emergency artificial respiration. JAMA 166: 1459–1460Google Scholar
  8. 8.
    Kouwenhoven WB, Jude JR, Knickerbocker GG (1960) Closed chest cardiac massage. JAMA 173: 1064–1067PubMedGoogle Scholar
  9. 9.
    The HACA Study Group (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346: 549–556CrossRefGoogle Scholar
  10. 10.
    Bernard S, 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
  11. 11.
    Nolan J, Soar J, Eikeland H (2006) The chain of survival. Resuscitation 71: 270–271CrossRefPubMedGoogle Scholar
  12. 12.
    Negovsky VA (1972) The second step in resuscitation—the treatment of the ‘post-resuscitation disease’. Resuscitation 1: 1–7CrossRefPubMedGoogle Scholar
  13. 13.
    Negovsky VA, Gurvitch AM (1995) Post-resuscitation disease—a new nosological entity. Its reality and significance. Resuscitation 30: 23–27CrossRefPubMedGoogle Scholar
  14. 14.
    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
  15. 15.
    Zijlstra F, Hoorntje JC, de Boer MJ, et al (1999) Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med 341: 1413–1419CrossRefPubMedGoogle Scholar
  16. 16.
    Wolfrum S, Pierau C, Radke PW, Schunkert H, Kurowski V (2008) Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 36: 1780–1786CrossRefPubMedGoogle Scholar
  17. 17.
    Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W (2007) Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction and its effect on outcome. Am J Emerg Med 25: 545–550CrossRefPubMedGoogle Scholar
  18. 18.
    Müller D, Schnitzer L, Brandt J. Arntz HR (2008) The accuracy of an out-of-hospital 12-lead ECG for the detection of ST-elevation myocardial infarction immediately after resuscitation. Ann Emerg Med 52: 658–664CrossRefPubMedGoogle Scholar
  19. 19.
    Polderman KH (2008) Induced hypothermia and fever control for prevention and treatment of neurological injuries. Lancet 371: 1955–1969CrossRefPubMedGoogle Scholar
  20. 20.
    Polderman KH, Sterz F, van Zanten ARH, et al (2003) Induced hypothermia improves neurological outcome in asystolic patients with out-of hospital cardiac arrest. Circulation 108:IV–581 (abst)Google Scholar
  21. 21.
    Van Lelyveld LE, Tjan DH, van Zanten AR (2008) Mild therapeutic hypothermia after cardiopulmonary resuscitation; patients over the age of 75. Intensive Care Med 34:S212 (abst)Google Scholar
  22. 22.
    Nolan JP, Morley PT, 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
  23. 23.
    Dixon SR, Whitbourn RJ, Dae MW, et al (2002) Induction of mild systemic hypothermia with endovascular cooling during primary percutaneous coronary intervention for acute myocardial infarction. J Am Coll Cardiol 40: 1928–1934CrossRefPubMedGoogle Scholar
  24. 24.
    Brooks SC, Morrison LJ (2008) Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: Seeking guidance from the knowledge translation literature. Resuscitation 77: 286–292CrossRefPubMedGoogle Scholar
  25. 25.
    Lemiale V, Huet O, Vigué B, et al (2008) in cerebral blood flow and oxygen extraction during post-resuscitation syndrome. Resuscitation 76: 17–24CrossRefPubMedGoogle Scholar
  26. 26.
    Nishizawa H, Kudoh I (1996) Cerebral autoregulation is impaired in patients resuscitated form cardiac arrest. Acta Anaesthesiol Scand 40: 1149–1153PubMedGoogle Scholar
  27. 27.
    Sakabe T, Tateishi A, Miyauchi Y, et al (1987) Intracranial pressure following cardiopulmonary resuscitation. Intensive Care Med 13: 256–259CrossRefPubMedGoogle Scholar
  28. 28.
    Leonov Y, Sterz F, Safar P, Johnson DW, Tisherman SA, Oku K (1992) Hypertension with hemodilution prevents multifocal cerebral hypoperfusion after cardiac arrest in dogs. Stroke 23: 45–53PubMedGoogle Scholar
  29. 29.
    Lewis WD, Chwals W, Benotti PN, et al (1988) Bedside assessment of the work of breathing. Crit Care Med 16: 117–122CrossRefPubMedGoogle Scholar
  30. 30.
    Schultz MJ, Determann RM, Wolthuis EK (2008) Ventilation with lower tidal volumes as compared with normal tidal volumes for patients without acute lung injury — a preventive randomized controlled trial. Intensive Care Med 34:S10 (abst)CrossRefGoogle Scholar
  31. 31.
    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
  32. 32.
    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
  33. 33.
    Behringer W, Bernard S, Holzer M, Polderman K, Tiainen M, Roine RO (2007) Prevention of post-resuscitation neurologic dysfunction and injury by the use of therapeutic hypothermia. In: Paradis NA, Halperin HR, Kern KB, Wenzel V, Chamberlain DA (eds) Cardiac Arrest._The Science and Practice of Resuscitation Medicine. 2nd edn. Cambridge University Press, Cambridge, pp 848–884Google Scholar
  34. 34.
    Fischer M, Böttiger BW, Popov-Cenic S, Hossmann KA (1996) Thrombolysis using plasminogen activator and heparin reduces cerebral no-reflow after resuscitation from cardiac arrest: an experimental study in the cat. Intensive Care Med 22: 1214–1223CrossRefPubMedGoogle Scholar
  35. 35.
    Rundgren M, Westhall E, Cronberg T, Ros’en I, H._Friberg H (2008) Amplitude integrated EEG (AEEG) predicts outcome in hypothermia treated cardiac arrest patients. Intensive Care Med 34:S102 (abst)Google Scholar
  36. 36.
    Nieuwendijk R, Struys AA, Gommers D, Simoons ML, Bakker J (2008) Treatment with induced hypothermia after out-of-hospital cardiac arrest has a high incidence of lower respiratory infections. Intensive Care Med 34:S211 (abst)CrossRefGoogle Scholar
  37. 37.
    Stoutenbeek CP, van Saene HFK, Miranda DR, Zandstra DF (1984) The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Medicine 10: 185–192CrossRefPubMedGoogle Scholar
  38. 38.
    de Jonge E, Schultz MJ, Spanjaard L, et al (2003) Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 362: 1011–1016CrossRefPubMedGoogle Scholar
  39. 39.
    Alam HB, Rhee P, Honma K, et al (2006) Does the rate of rewarming from profound hypothermic arrest influence the outcome in a swine model of lethal hemorrhage? J Trauma 60: 134–146CrossRefPubMedGoogle Scholar
  40. 40.
    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
  41. 41.
    Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S, Quality Standards Subcommittee of the American Academy of Neurology (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
  42. 42.
    Reisinger J, Höllinger K, Lang W (2007) Prediction of neurological outcome after cardiopulmonary resuscitation by serial determination of serum neuron-specific enolase. Eur Heart J 28: 52–58CrossRefPubMedGoogle Scholar
  43. 43.
    Aufderheide TP, Lurie KG (2006) Vital organ blood flow with the impedance threshold device. Crit Care Med 34:S466–473CrossRefGoogle Scholar
  44. 44.
    Busch H, Brunner M, Schwab H, Inderbitzen B, Barbut D, Schwab T (2008) Pre-treatment with trans-nasal cooling for the induction of therapeutic hypothermia in patients with cardiac arrest leads to a significant faster achievement of target temperature during systemic cooling. Intensive Care Med 34:S250 (abst)CrossRefGoogle Scholar
  45. 45.
    Ewy GA (2007) Cardiac arrest—guideline changes urgently needed. Lancet 369: 882–884CrossRefPubMedGoogle Scholar
  46. 46.
    Sayre MR, Berg RA, Cave DM, et al (2008) Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation 117: 2162–2167CrossRefPubMedGoogle Scholar
  47. 47.
    Damian MS, Ellenberg D, Gildemeister R, et al (2004) Coenzyme Q10 combined with mild hypothermia after cardiac arrest: a preliminary study. Circulation 110: 3011–3016CrossRefPubMedGoogle Scholar
  48. 48.
    Cariou A, Claessens YE, Pène F, et al (2008) Early high-dose erythropoietin therapy and hypothermia after out-of-hospital cardiac arrest: a matched control study. Resuscitation 76: 397–404CrossRefPubMedGoogle Scholar
  49. 49.
    Sasson C, Hegg AJ, Macy M, Park A, Kellermann A, McNally B, CARES Surveillance Group (2008) Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest. JAMA 300: 1432–1438CrossRefPubMedGoogle Scholar
  50. 50.
    Arawwawala D, Brett SJ (2007) Clinical review: beyond immediate survival from resuscitation-long-term outcome considerations after cardiac arrest. Crit Care 11:235CrossRefPubMedGoogle Scholar
  51. 51.
    Williams GR, Spencer FC (1958) The clinical use of hypothermia following cardiac arrest. Ann Surg 148: 462–468CrossRefPubMedGoogle Scholar
  52. 52.
    Benson DW, Williams GR, Spencer FC, Yates AT (1959) The use of hypothermia after cardiac arrest. Anesth Analg 38: 423–428CrossRefPubMedGoogle Scholar
  53. 53.
    Bernard SA, Jones BM, Horne MK (1997) Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest. Ann Emerg Med 30: 146–153CrossRefPubMedGoogle Scholar
  54. 54.
    Yanagawa Y, Ishihara S, Norio H, et al (1998) Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest. Resuscitation 39: 61–66CrossRefPubMedGoogle Scholar
  55. 55.
    Nagao K, Hayashi N, Kanmatsuse K, et al (2000) Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital. J Am Coll Cardiol 36: 776–783CrossRefPubMedGoogle Scholar
  56. 56.
    Zeiner A, Holzer M, Sterz F, et al (2000) Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest. A clinical feasibility trial. Stroke 31: 86–94PubMedGoogle Scholar
  57. 57.
    Mori K, Takeyama Y, Itoh Y, et al (2000) A multivariate analysis of prognostic factors in survivors of out-of-hospital cardiac arrest with brain hypothermia therapy. Crit Care Med 28 (12 suppl): A168 (abst)Google Scholar
  58. 58.
    Felberg RA, Krieger DW, Chuang R, et al (2001) Hypothermia after cardiac arrest: feasibility and safety of an external cooling protocol. Circulation 104: 1799–1804CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2009

Authors and Affiliations

  • M. A. Kuiper
    • 1
  • P. E. Spronk
    • 2
  • M. J. Schultz
    • 3
  1. 1.Department of Intensive CareMedical Center LeeuwardenLeeuwardenNetherlands
  2. 2.Department of Intensive CareGelre Hospitals (Lukas site)ApeldoornNetherlands
  3. 3.Department of Intensive Care and Laboratory of Experimental Intensive Care and AnesthesiologyAcademic Medical Center at the University of AmsterdamAmsterdamNetherlands

Personalised recommendations