Haemodynamic changes to a midazolam–fentanyl–rocuronium protocol for pre‐hospital anaesthesia following return of spontaneous circulation after cardiac arrest

Abstract

Following the return of spontaneous circulation after out-of-hospital cardiac arrest, neurological dysfunction, airway or ventilatory compromise can impede transport to early percutaneous coronary intervention, necessitating pre-hospital or emergency department anaesthesia to facilitate this procedure. There are no published reports of the ideal induction agents in these patients. We sought to describe haemodynamic changes associated with induction of anaesthesia using a midazolam (0.1 mg.kg ), fentanyl (2 μg.kg ) and rocuronium (1 mg.kg ) regimen developed using expert opinion, and adherence to the protocol by our pre-hospital teams. We performed a retrospective review of haemodynamic data recorded during induction of anaesthesia in patients following return of spontaneous circulation, over a 30-month period. We analysed the changes in systolic blood pressure and heart rate using a repeated-measures design, as well as the rate of new hypotension or hypertension. Sixty-four patients had four consecutive measurements for analysis (one pre-induction and three post-induction). Systolic blood pressure at all three post-induction measurements was significantly lower than the pre-induction value. Heart rate did not differ between any time-points. New episodes of hypotension (systolic pressure < 90 mmHg) occurred in four (6%) patients at the first measurement post-induction (95%CI 2-15%) and 10 (16%) at the third measurement (95%CI 8-27%). Three patients (5%; 95%CI 1-13%) had a hypertensive response. The median (IQR[range]) dose of midazolam given at induction was 0.04 (0.03-0.05 [0.01 to 0.10]) mg.kg . Adherence to recommended fentanyl and rocuronium doses was high. Overall, systolic blood pressure was reduced following induction of anaesthesia, and systolic pressures < 90 mmHg occurred more often at measurements made later (up to 9 min) after induction. Changes in heart rate, and new hypertension were uncommon.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

“…The same level of care should be provided as for any other critically ill patient in terms of skills of the provider, monitoring, and choice of drugs. 63,64 There are no recommendations for a specific drug combination, 65 but use of a low dose of a sedative, an analgesic and a rapid onset neuromuscular blocking drug is probably optimal.…”

Cardiovascular complications of prehospital emergency anaesthesia in patients with return of spontaneous circulation following medical cardiac arrest: a retrospective comparison of ketamine-based and midazolam-based induction protocols

“…The cumulative incidence of hypotension increased significantly over time, and within 3, 6 and 9 min was 6.2%, 15.6% and 31.2%, respectively. 13 Increasingly, the authors feel that studies reporting only early hypotension miss a significant number of patients in the 10-30 min window where the sympathetic simulation of laryngoscopy and packaging for transfer have abated.…”

“…12 However, our own service has demonstrated an acceptable cardiovascular profile following PHEA with a standardised fentanyl-midazolam-rocuronium induction. 13 The objective of this study was to assess the haemodynamic stability of two different induction agents for post-cardiac arrest medical patients requiring PHEA.…”

Postreanimationsbehandlung

“…Bezogen auf die Fähigkeiten des Behandelnden, die Überwachung und die Auswahl der Medikamente soll das gleiche Maß an Sorgfalt wie für jeden anderen schwerkranken Patienten gewährleistet werden [66,67]. Es gibt keine Empfehlungen für eine bestimmte Wirkstoffkombination [68]. Die Verwendung einer niedrigen Dosis eines Sedativums, eines Analgetikums und eines schnell-wirksamen Muskelrelaxans ist wahrscheinlich optimal.…”