Elsevier

Resuscitation

Volume 79, Issue 3, December 2008, Pages 350-379
Resuscitation

ILCOR Consensus Statement
Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke,☆☆,

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Summary

Aim of the review

To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome.

Methods

Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment.

Results

The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology.

Conclusions

A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.

Section snippets

Consensus process

The contributors of this statement were selected to ensure expertise in all the disciplines relevant to post-cardiac arrest care. In an attempt to make this document universally applicable and generalisable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post-cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations

Background

This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimizing post-cardiac arrest care and pinpointing the need for research focused on gaps in knowledge that would potentially improve outcomes of patients resuscitated from cardiac arrest.

Resumption of spontaneous circulation after prolonged complete

Epidemiology of the post-cardiac arrest syndrome

The tradition in cardiac arrest epidemiology, based largely on the Utstein consensus guidelines, has been to report percentages of patients who survive to sequential end points such as ROSC, hospital admission, hospital discharge, and various points thereafter.15, 16 Once ROSC is achieved, however, the patient is technically alive. A more useful approach to studying post-cardiac arrest syndrome is to report deaths during various phases of post-cardiac arrest care. In fact, this approach reveals

Pathophysiology of the post-cardiac arrest syndrome

The high mortality rate of patients who initially achieve ROSC after cardiac arrest can be attributed to a unique pathophysiological process involving multiple organs. Although prolonged whole-body ischaemia initially causes global tissue and organ injury, additional damage occurs during and after reperfusion.28, 29 The unique features of post-cardiac arrest pathophysiology are often superimposed on the disease or injury that caused the cardiac arrest as well as underlying co-morbidities.

Therapeutic strategies

Care of the post-cardiac arrest patient is time-sensitive, occurs both in- and out-of-hospital, and is sequentially provided by multiple diverse teams of healthcare providers. Given the complex nature of post-cardiac arrest care, it is optimal to have a multidisciplinary team develop and execute a comprehensive clinical pathway tailored to available resources. Treatment plans for post-cardiac arrest care must accommodate a spectrum of patients, ranging from the awake, haemodynamically stable

Post-cardiac arrest prognostication

With the brain’s heightened susceptibility to global ischaemia, the majority of cardiac arrest patients who are successfully resuscitated have impaired consciousness, and some remain in a vegetative state. The need for protracted high-intensity care of neurologically devastated survivors presents an immense burden to healthcare systems, patients’ families, and society in general.251, 252 To limit this burden, clinical factors and diagnostic tests are used to prognosticate functional outcome.

Paediatrics: special considerations

In children, cardiac arrests are caused typically by respiratory failure, circulatory shock or both. In contrast to adults, children rarely develop sudden arrhythmogenic VF arrests from coronary artery disease. Arrhythmogenic VF/ventricular tachycardia (VT) arrests occur in 5–20% of out-of-hospital paediatric cardiac arrests and approximately 10% of in-hospital paediatric arrests.5, 20, 330, 331, 332

Although clinical data are limited, differences in both cardiac arrest aetiology and

Challenges to implementation

Publication of clinical guidelines alone is frequently inadequate to change practice. There are often several barriers to changing clinical practice, and these will need to be identified and overcome before changes can be implemented. The purpose of the following section is to provide insight into the challenges and barriers to implementing optimized post-cardiac arrest care.

Critical knowledge gaps

In addition to summarizing what is known about the pathophysiology and management of post-cardiac arrest syndrome, a goal of this statement is to highlight what is not known. Table 5 outlines the critical knowledge gaps identified by the writing group. The purpose of this list is to stimulate preclinical and clinical research that will lead to evidence-based optimization of post-cardiac arrest care.

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    A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2008.09.017.

    ☆☆

    Endorsed by the American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and Neurocritical Care Society.

    This article has been copublished in Circulation.

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