Implementation of a Post-Cardiac Arrest Care Bundle Including Therapeutic Hypothermia and Hemodynamic Optimization in Comatose Patients with Return of Spontaneous Circulation After Out-of-Hospital Cardiac Arrest

Abstract

Patients who present to the emergency department (ED) with return of spontaneous circulation after cardiac arrest generally have poor outcomes. Guidelines for treatment can be complicated and difficult to implement. This study examined the feasibility of implementing a care bundle including therapeutic hypothermia (TH) and early hemodynamic optimization for comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest. The study included patients over a 2-year period in the ED and intensive care unit of an academic tertiary-care medical center. The first year (prebundle) provided a historical control, followed by a prospective observational period of bundle implementation during the second year. The bundle elements included (a) TH initiated; (b) central venous pressure/central venous oxygen saturation monitoring in 2 h; (c) target temperature in 4 h; (d) central venous pressure greater than 12 mmHg in 6 h; (e) MAP greater than 65 mmHg in 6 h; (f) central venous oxygen saturation greater than 70% in 6 h; (g) TH maintained for 24 h; and (h) decreasing lactate in 24 h. Fifty-five patients were enrolled, 26 patients in the prebundle phase and 29 patients in the bundle phase. Seventy-seven percent of bundle elements were completed during the bundle phase. In-hospital mortality in bundle compared with prebundle patients was 55.2% vs. 69.2% (P = 0.29). In the bundle patients, those patients who received all elements of the care bundle had mortality 33.3% compared with 60.9% in those receiving some of the bundle elements (P = 0.22). Bundle patients tended to achieve good neurologic outcome compared with prebundle patients, Cerebral Performance Category 1 or 2 in 31 vs. 12% patients, respectively (P = 0.08). Our study demonstrated that a post-cardiac arrest care bundle that incorporates TH and early hemodynamic optimization can be implemented in the ED and intensive care unit collaboratively and can achieve similar clinical benefits compared with those observed in previous clinical trials.

Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges

“…85 Coronary artery disease is the most common trigger for out-of-hospital cardiac arrest and is identified in at least two thirds of patients who are resuscitated and undergo coronary angiography. 61 Twelve-lead ECG should be performed immediately after return of spontaneous circulation in the absence of an obvious noncardiac cause to identify ST-segment elevation myocardial infarction, which 79 Walters et al, 80 and Sunde et al 81 (Adapted from Jentzer et al 52 Used with permission.) is found in 25% to 30% of patients resuscitated from outof-hospital cardiac arrest.…”

“…51,52 Observational studies suggest that early 75 Sutherasan et al, 77 and Geri et al 86 hemodynamic optimization as part of a postarrest care bundle can improve outcomes, analogous to management of septic shock ( Figure 4). 52,[79][80][81] Patients often require fluid resuscitation after return of spontaneous circulation, although this should be guided by measures of preload responsiveness and intravascular volume status to avoid volume overload. 51,52,76 Hypotension refractory to fluids typically responds to vasopressors.…”

Canadian Guidelines for the use of targeted temperature management (therapeutic hypothermia) after cardiac arrest: A joint statement from The Canadian Critical Care Society (CCCS), Canadian Neurocritical Care Society (CNCCS), and the Canadian Critical Care Trials Group (CCCTG)

“…Walters et al implemented a care bundle that included TTM and hemodynamic optimization targets 147 . In a pre-post design of 55 patients, the implementation of the care bundle was associated with a trend towards reduced mortality and improved neurological outcome.…”

Use of a Nursing Checklist to Facilitate Implementation of Therapeutic Hypothermia After Cardiac Arrest

“…The implementation of institution-specific standardized protocols, order sets, and a bundled care approach have proven a successful method in combating the barriers to implementation of therapeutic hypothermia [14][15][16][17][18][19][20] and were associated with an increased efficiency in achieving target temperature. 21,22 The effectiveness of a surgical safety checklist on rates of postoperative death and complications was documented by Haynes et al, 23 who reported a decrease in death rate and complication rate after implementation of a checklist.…”

“…Relying on a standardized protocol improves the quality and outcomes of an intervention such as therapeutic hypothermia. 9,[16][17][18]20,22 Checklists have also been used as tools to increase the quality and safety in many industries and have gained popularity in health care. Checklists standardize the tasks that must be completed and provide a transparent framework to ensure protocol adherence, all while establishing a process to share information and support among caregivers.…”