Sedation and shivering management after cardiac arrest

Abstract

Management of sedation and shivering during targeted temperature management (TTM) after cardiac arrest is limited by a dearth of high-quality evidence to guide clinicians. Data from general intensive care unit (ICU) populations can likely be extrapolated to post cardiac arrest patients, but clinicians should be mindful of key differences that exist between these populations. Most importantly, the goals of sedation after cardiac arrest are distinct from other ICU patients, and may also involve suppression of shivering during TTM. Drug metabolism and clearance is altered considerably during TTM when a low goal temperature is used, which can delay accurate neuroprognostication. When neuromuscular blockade is used to prevent shivering, sedation should be deep enough to prevent awareness and providers should be aware that this can mask clinical manifestations of seizures. However, excessively deep or prolonged sedation is associated with complications including delirium, infections, increased duration of ventilatory support, prolonged ICU length of stay, and delays in neuroprognostication. In this manuscript, we review sedation and shivering management best practices in the post cardiac arrest patient population.

Postresuscitation management

“…Furthermore, the role of sedation is currently under evaluation in the ongoing Sedation, Temperature, and Pressure After Cardiac Arrest and Resuscitation (STEPCARE) study (NCT05564754), which seeks to randomize unconscious cardiac arrest patients to either continuous deep sedation for 36 h or minimal sedation/early withdrawal. The use of neuromuscular blockade (NMB) is another contentious aspect of management; while NMB can effectively achieve target temperatures and control refractory shivering, it may also lead to prolonged ventilatory support, extended ICU stays, and muscular weakness [61]. A recent systematic review highlighted that the utilization of a prophylactic NMB strategy, as opposed to not using NMBA, was linked to improved survival rates and improved neurological outcomes in cardiac arrest patients undergoing TTM [62]; nevertheless, only few and small sample size RCTs are currently available and further research is warranted to validate these findings.…”

Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review

“…Neuromuscular block (NMB) is commonly used in perioperative care for a variety of circumstances. It can optimize surgical conditions [1], facilitate tracheal intubation, and be used in the intensive care unit (ICU) to improve chest wall compliance, reduce abdominal pressure, prevent and treat shivering, and reduce elevation in intracranial pressure from the airway reactivity [2,3]. In the emergency department (ED) and areas outside of the operating room and procedural areas, NMB can be used for rapid sequence induction and intubation (RSII), a technique used by healthcare professionals to minimize pulmonary aspiration [4].…”