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department: Heart Beats

Are you ready to care for your patient after a code?

Palatnik, AnneMarie APN, BC, MSN; Foran, Leslie RN

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In Brief

Though a significant amount of recent literature exists regarding the revisions in the American Heart Association's (AHA) recommendations for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC), there has been little published about the importance of supportive care post resuscitation. Nurses need to remain aware of the considerations they should take after succeeding in reviving a patient.

After CPR

Patient mortality remains high after the spontaneous return of circulation.1 Care should optimize hemodynamic stability by identifying and treating any reversible causes of arrest and maintaining regulation of temperature and glucose control.

In developing the recent recommendations for CPR and ECC, the AHA defines the levels of evidence (LOE) for recommendations with a grading system that ranges from LOE 1 to LOE 8. Level one, the strongest level in the graded scale, is evidence based on randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects. The eighth level in the grading scale is the weakest level, based upon rational ideas or common and accepted practices. Consider a review of the recommendations for post resuscitation support, which are directed toward optimizing:

  • ventilation
  • temperature control
  • seizure control
  • other supportive therapies, including blood glucose control, coagulation control, and prophylactic antiarrhythmic therapy.1,2

Arterial carbon dioxide level

Experts have used hyperventilation for oxygenation in unconscious patients. However, there's limited evidence that hyperventilation protects the brain from ischemia. Hyperventilation post resuscitation increases vasoconstriction and decreases cerebral blood flow, allowing for greater cerebral ischemia, which causes greater patient morbidity. It's more important to maintain normal PaCO2 levels post resuscitation from cardiac arrest. The LOE for studies supporting this therapy range from level 2 through level 7.2

Therapeutic hypothermia

When return of spontaneous circulation takes place, the key element in improving neurological outcomes is preventing hyperthermia. Studies have shown that maintaining a hypothermic state reduces oxygen supply and demand, which is needed for brain recovery. Clinical studies have shown that mild degrees of hypothermia, 327 °C to 347 °C (89.67 °F to 93.27 °F) for 12 to 24 hours post resuscitation has improved patient outcomes (LOE 1 and 2).1–2 Close monitoring of the patient's hemodynamic status and temperature is vital. Methods that cool patients externally include hypothermia blankets or ice bag applications. Internal cooling can be obtained by using cold saline or endovascular cooling catheters.2

Preventing hyperthermia

Temperature elevation is common in post cardiac arrest or brain injury patients. It's important to monitor the patient's temperature and avoid hyperthermia post resuscitation, as it increases the oxygen requirements of the brain. Morbidity and mortality increase with each degree of body temperature greater than 377 °C (98.67 °F) (LOE 3). Therefore, using a combination of antipyretics and external cooling devices will help control the patient's temperature.2

Seizures

Seizure causes an increase in oxygen demand on the brain and can cause life-threatening arrhythmias. Nurses should treat witnessed seizures and start maintenance anticonvulsants.1 There's little data in the literature to show that prophylactic anticonvulsant drugs should be given. Take measures to rule out such factors as electrolyte imbalances and intracranial hemorrhage as a source of seizures. Note that some data indicate seizures can precipitate cardiac arrest (LOE 4 and 5).2

Blood glucose control

Electrolyte abnormalities post resuscitation are often detrimental to a successful recovery. Several studies have shown a direct correlation between high blood glucose levels post resuscitation and poor neurological outcomes (LOE 4 and 5).2 However, these studies didn't conclude that control of serum glucose levels altered outcomes. Research has shown that in the general critically ill population, tight glucose control (80 to 110 mg/dL) with insulin reduces mortality (LOE 1 and 4).2 Post resuscitation, nurses should maintain frequent monitoring of blood glucose levels. Treat hyperglycemia with insulin, but take care to avoid hypoglycemia.

Anticoagulation therapy

There haven't been any clinical studies that specifically evaluate anticoagulation's role in improving outcomes after the return of spontaneous circulation. However, there have been some anecdotal reports that fibrinolytics in conjunction with heparin have positively impacted outcomes (LOE 4, 5, and 6).2

Prophylactic antiarrhythmic therapy

There have been no clinical studies to directly evaluate the prophylactic use of antiarrhythmic therapy started immediately upon return of spontaneous circulation. However, experts report some inconsistent long-term survival when prophylactic antiarrhythmics were used (LOE 5).2

Conversely, implantable cardioverter defibrillators have been shown to improve survival when compared to antiarrhythmics in the post resuscitation patient population in six separate trials (LOE 1, 2, and 3). Because of these clinical trials, the use of prophylactic antiarrhythmics in patients who've had spontaneous return of circulation is neither recommended nor rejected. Nevertheless, it's reasonable to maintain a continuous infusion of an antiarhythmic agent that was successful in restoring a stable rhythm during resuscitation.2

Stabilize and correct

Appropriate post resuscitation care has the potential to significantly improve intact neurologic survival. During the post resuscitation care period, every system is at risk and the patient has the high likelihood of developing multiorgan dysfunction and ultimately organ failure. Healthcare providers should direct care toward stabilizing hemodynamic instabilities and correcting metabolic and neurologic abnormalities.

Additional information in treating post resuscitation patients can be found on the AHA's Web site, http://www.heart.org, under the “CPR & ECC” link.

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REFERENCES

1. American Heart Association. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7.5: post resuscitation support. Circulation. 2005;IV-84–IV-88.
2. American Heart Association. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: advanced life support. Circulation. 2005;III-37–III-38.
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