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L’arrêt cardiaque inattendu en réanimation : état des lieux et perspectives

Unexpected cardiac arrest in the intensive care unit: State-of-the-art and perspectives

  • Mise Au Point / Update
  • Published:
Médecine Intensive Réanimation

Résumé

En réanimation et plus généralement en secteur de médecine intensive, l’arrêt cardiaque est un événement rare qui survient dans un environnement favorable à une prise en charge rapide et adaptée. Cependant, les patients hospitalisés dans ce type d’unités souffrent de maladies chroniques et de défaillances d’organes qui réduisent les chances de survie après un tel événement. Près de 50 % des patients souffrant d’un arrêt cardiaque inattendu en réanimation sont initialement réanimés avec succès, mais un grand nombre décède dans les 24 heures suivant la récupération d’une activité circulatoire spontanée. Le taux de survie à la sortie de l’hôpital est d’environ 15 %. Les facteurs pronostiques de l’arrêt cardiaque se répartissent en trois catégories: i) les facteurs liés au patient; ii) à l’arrêt; iii) aux suites de l’arrêt. Les facteurs associés à une évolution défavorable sont les infections respiratoires, la pathologie traumatique, le cancer, l’insuffisance rénale, les défaillances d’organes, les comorbidités associées. Une hypotension, un sepsis, une aggravation des scores physiologiques de gravité avant l’arrêt cardiaque sont également de mauvais pronostic. Les arrêts par fibrillation ou tachycardie ventriculaire ont un meilleur pronostic que les arrêts en asystolie ou en dissociation électromécanique. Une réanimation cardiopulmonaire prolongée réduit les chances de survie sans séquelle, même en cas de ressuscitation initiale. Le pronostic de l’arrêt cardiaque peut être amélioré par la détection d’événements précurseurs (hypoxie, hypovolémie, acidose notamment) et par une formation régulière des soignants aux techniques de ressuscitation. Enfin, un projet thérapeutique élaboré au cas par cas, proportionné aux comorbidités et excluant dans certaines circonstances toute manœuvre de ressuscitation, permet à l’échelle d’un service de réduire la proportion des arrêts cardiaques inutilement réanimés.

Abstract

Unexpected cardiac arrest is a rare event in the Intensive Care Unit (ICU). Despite immediate availability of advanced life support and trained staff, patients suffer from chronic diseases and organ failures that worsen the prognosis for cardiac arrest victims. Although the initial success rate of cardiopulmonary resuscitation may be high, most of the resuscitated patients die soon after restoration of spontaneous circulation. Studies report the percentage of patients surviving to hospital discharge to be about 15%. Factors associated with prognosis are divided into three groups: pre-arrest, intra-arrest, and post-arrest. Preexisting conditions associated with poor outcome are pneumonia, trauma, malignancy, renal insufficiency, organ failures, and comorbidities. Hypotension, sepsis and worsening of Acute Physiology Scores before arrest are more common among the non-survivors. Patients with ventricular tachycardia or fibrillation compared to non-shockable rhythms are more likely to survive. Even though spontaneous circulation is initially restored, the rate of patients discharged alive from hospital declines with the duration of cardiopulmonary resuscitation. However, cardiac arrest is frequently preceded by warning signs of clinical deterioration (hypoxia, hypovolemia, acidosis for instance) that can be identified and treated. Cautious anticipation, regular training, timely initiation of rescue, and selection of patients most likely to benefit from resuscitation are key steps to enhance prognosis and quality of life for cardiac arrest patients in the ICU.

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Abbreviations

ACIH:

arrêt cardiaque intrahospitalier

ACIR:

arrêt cardiaque inattendu en réanimation

APACHE:

Acute Physiology and Chronic Health Evaluation

CEE:

choc électrique externe

CPC:

Cerebral Performance Category

DEM:

dissociation électromécanique

FV:

fibrillation ventriculaire

GWTG-R:

Get with the Guidelines ® Registry

MCE:

massage cardiaque externe

MPM:

Mortality Probability Model

RACS:

récupération d’une activité circulatoire spontanée

RCP:

réanimation cardiopulmonaire

SAPS:

Simplified Acute Physiology Score

SOFA:

Sequential Organ Failure Assessment

TV:

tachycardie ventriculaire

USI:

unité de soins intensifs

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  1. Intensive Care Unit, Saint-Louis Hospital, F-17019, La Rochelle, France

    O. Lesieur & M. Leloup

  2. EA4569, université Paris-Descartes, F-75006, Paris, France

    O. Lesieur

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Lesieur, O., Leloup, M. L’arrêt cardiaque inattendu en réanimation : état des lieux et perspectives. Méd. Intensive Réa 26, 411–424 (2017). https://doi.org/10.1007/s13546-017-1296-6

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