The intensive care treatment of cardiac arrest survivors has evolved considerably over the past 10 years. In 2005 the European Resuscitation Council (ERC) Guidelines for Advanced Life Support included less than three pages of text on post-resuscitation care [1]. Since 2005, the management of post-cardiac arrest patients has achieved a much higher profile within the specialty of critical care medicine, a fact that is reflected by the substantial increase in the number of studies published in this field. Although the ERC and the American Heart Association (AHA) both published post-resuscitation care guidelines in 2010 [2, 3], this year, for the first time, the ERC has collaborated with the European Society of Intensive Care Medicine (ESICM) to produce European post-resuscitation care guidelines [4].
Since 2000, ILCOR has published its International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science with Treatment Recommendations (CoSTR) in 5-year cycles. The most recent ILCOR 2015 International Consensus Conference on CPR Science was held in Dallas in February 2015; the consensus science statements and treatment recommendations were published simultaneously in Resuscitation and Circulation [5, 6].
As part of the 2015 evidence evaluation process, the ILCOR advanced life support (ALS) task force reviewed post-resuscitation care topics. Using the PICO (population, intervention, comparator, outcome) format, questions were identified and prioritised and experts working in pairs completed detailed systematic reviews. The task force used the methodological approach for evidence evaluation and development of recommendations proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. A detailed search for relevant articles was performed in each of three online databases (MEDLINE, Embase, and the Cochrane Library) [7]. The quality of the evidence (or confidence in the estimate of the effect) was categorised as high, moderate, low or very low, based on the study methodologies and the risk of bias, inconsistency, indirectness, imprecision and publication bias. Written summaries of evidence for each outcome (the Consensus on Science statements) were drafted by the evidence reviewers and then discussed, debated and refined by the task forces until consensus was reached. Finally, consensus-based treatment recommendations were designated as strong or weak and either for or against a therapy or diagnostic test [5, 8].
The 2015 CoSTR underpins the 2015 ERC and ESICM post-resuscitation care guidelines. The treatment recommendations in CoSTR reflect the available science and the international consensus that could be achieved—in most cases the recommendations lack the detail that is required to inform the resuscitation practitioner precisely how to treat the patient. The ERC-ESICM guidelines on post-resuscitation care are intended to be much more practical and more didactic, i.e. they tell the clinician exactly what to do. They cover the whole post-cardiac arrest patient pathway and include elements of pre-hospital care, in-hospital treatment and finally rehabilitation.
Animal studies suggest that after return of spontaneous circulation (ROSC), hyperoxia may worsen neurological injury [9]. Clinical data on neurological injury are conflicting but a recent study of air versus supplemental oxygen in ST-elevation myocardial infarction showed deleterious effects of oxygen treatment [10]. As soon as arterial blood oxygen saturation can be monitored reliably, the ERC-ESICM recommendation is to titrate the inspired oxygen concentration to maintain the arterial blood oxygen saturation in the range of 94–98 %. As yet, there are no prospective data defining an optimal plasma carbon dioxide target in the post-cardiac arrest patient, and observational data are inconsistent. Until further data are available the recommendation is to aim for normocarbia.
If cardiac arrest has been caused by an acute coronary occlusion, achieving coronary reperfusion as soon as possible is a high priority. Emergent cardiac catheterisation laboratory evaluation (and immediate percutaneous coronary intervention (PCI) if required) should be performed in adult patients with ROSC after out-of-hospital cardiac arrest (OHCA) of suspected cardiac origin with ST-elevation (STE) on the ECG. This recommendation is relatively non-controversial; the management of those patients with a likely cardiac cause of their cardiac arrest but without STE on the ECG is less well defined. In general, it is reasonable to discuss and consider emergent cardiac catheterisation laboratory evaluation after ROSC in patients with the highest risk of a coronary cause for their cardiac arrest. The ERC-ESICM guidelines include recommendations on the timing of computed tomography (CT) scanning in relation to coronary catheterisation and these are summarised in a post-cardiac arrest algorithm.
The prevention of post-ROSC hyperthermia and the implementation of targeted temperature management (TTM) remains a strong recommendation in the ERC-ESICM guidelines. There is no international consensus on the precise target temperature—the current recommendation is to maintain a constant temperature in the range 32–36 °C for 24 h [11].
Predicting the final neurological outcome of those who remain comatose after resuscitation from cardiac arrest is problematic and it is now generally accepted that decisions about withdrawal of life-sustaining treatment (WLST) have been made far too early. The ERC and ESICM have already published guidelines on prognostication after cardiac arrest [12] and these have been incorporated into the 2015 post-resuscitation care guidelines. The principles of prognostication are that it is generally delayed until at least 3 days after cardiac arrest and it is multimodal.
Many cardiac arrest survivors have cognitive and emotional problems long after hospital discharge. To date, there have been few structured programmes to rehabilitate these patients and this is a component of the patient pathway that can be improved considerably. The ERC-ESICM guidelines provide recommendations on the follow-up care for post-cardiac arrest patients.
Since 2010, considerable progress in clinical research has created important advances, making these post-resuscitation guidelines immediately applicable in many patients. However, there are still knowledge gaps, which require further investigation. Temperature management is probably the field in which most questions remain unsolved. Should we use a specific cooling technique? What is the best sedation strategy during cooling? Who are the best candidates for a lower target temperature target (32–34 °C) [13]? Should we start cooling during transport to hospital? As early pneumonia is very frequent in cooled patients, should we give prophylactic antibiotics? Ongoing clinical studies might provide definitive conclusions in the very near future. The optimal management of post-resuscitation circulatory failure also remains controversial. Although some clinical data suggest 75 mmHg as a target for mean arterial pressure, this should be further investigated in prospective studies. The use of steroids during the post-resuscitation shock also requires further exploration. Brain injury is the cornerstone of outcome: new imaging and electrophysiological investigations will help to refine the neuroprognostication strategy that has been proposed. Finally, follow-up care for survivors is now recommended but we need high-level evidence for this rehabilitation phase [14].
While further science is awaited, we sincerely hope that these 2015 guidelines will help intensive care clinicians to treat their post-cardiac arrest patients.
References
Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G (2005) European Resuscitation Council guidelines for resuscitation 2005, section 4. Adult advanced life support. Resuscitation 67(Suppl 1):S39–S86
Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, Perkins GD (2010) European Resuscitation Council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation 81:1305–1352
Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL (2010) Part 9: post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122:S768–S786
Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger B, Friberg H, Sunde K, Sandroni C (2015) European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care. Intensive Care Med. doi:10.1007/s00134-015-4051-3 (co-publication with Resuscitation)
Nolan JP, Hazinski MF, Aicken R, Bhanji F, Billi J, Callaway CW, Castren M, de Caen A, Finn J, Iverson S, Lang E, Lim SH, Maconochie I, Montgomery W, Morley M, Nadkarni V, Neumar R, Nikolaou N, Perkins GD, Perlman J, Singletary N, Soar J, Travers A, Welsford M, Witt J, Wylie J, Zideman DA (2015) Part I. Executive summary: 2015 International Consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 95:e1–e32
Hazinski MF, Nolan JP, Aicken R, Bhanji F, Billi J, Callaway CW, Castren M, de Caen A, Finn J, Iverson S, Lang E, Lim SH, Maconochie I, Montgomery W, Morley M, Nadkarni V, Neumar R, Nikolaou N, Perkins GD, Perlman J, Singletary N, Soar J, Travers A, Welsford M, Witt J, Wylie J, Zideman DA (2015) Part I. Executive summary: 2015 International Consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 132(suppl 1)
Morley PT, Lang E, Aickin R, Billi J, Finn J, Maconochie I, Morrison L, Nolan JP, Perkins G, Sayre M, Wyllie J, Zideman DA, Nadkarni V, Nikolaou NI (2015) Part 2: Evidence evaluation and management of conflict of interest for the ILCOR 2015 Consensus on science and treatment recommendations. Resuscitation 95:e33–e41
Soar J, Callaway CW, Aibiki M, Bottiger B, Brooks S, Deakin C, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison L, Neumar R, Nicholson T, Nolan JP, Okada K, O’Neil B, Paiva E, Parr M, Wang T-L, Witt J, on behalf of the Advanced Life Support Chapter Collaborator (2015) Part 4: Advanced life support: 2015 International Consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 95:e71–e122
Pilcher J, Weatherall M, Shirtcliffe P, Bellomo R, Young P, Beasley R (2012) The effect of hyperoxia following cardiac arrest—a systematic review and meta-analysis of animal trials. Resuscitation 83:417–422
Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, Cameron P, Barger B, Ellims AH, Taylor AJ, Meredith IT, Kaye DM, Investigators* A (2015) Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation 131:2143–2150
Donnino M, Andersen LW, Berg KM, Reynolds JC, Nolan JP, Morley PT, Lang E, Cocchi MN, Xanthos T, Callaway CW, Soar J (2015) Temperature management after cardiac arrest. An advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee. Resuscitation. doi:10.1016/j.resuscitation.2015.09.396
Sandroni C, Cariou A, Cavallaro F, Cronberg T, Friberg H, Hoedemaekers C, Horn J, Nolan JP, Rossetti AO, Soar J (2014) Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Intensive Care Med 40:1816–1831
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Aneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Kober L, Langorgen J, Lilja G, Moller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H, Investigators TTMT (2013) Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 369:2197–2206
Moulaert VR, van Heugten CM, Winkens B, Bakx WG, de Krom MC, Gorgels TP, Wade DT, Verbunt JA (2015) Early neurologically-focused follow-up after cardiac arrest improves quality of life at one year: a randomised controlled trial. Int J Cardiol 193:8–16
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Rights and permissions
About this article
Cite this article
Nolan, J.P., Cariou, A. Post-resuscitation care: ERC–ESICM guidelines 2015. Intensive Care Med 41, 2204–2206 (2015). https://doi.org/10.1007/s00134-015-4094-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-015-4094-5