Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2013
ReviewSOPs and the right hospitals to improve outcome after cardiac arrest.
Approximately 400,000 Europeans are yearly resuscitated from out-of-hospital cardiac arrest (OHCA).(1,2) Despite evolving evidence based guidelines for cardiopulmonary resuscitation (CPR), survival rates after OHCA has not improved much in several places around the world. However, a potential for improved survival is absolutely present, based on the huge spread in worldwide survival; some cities with survival over 20-30% and some cities with just a few percent.(1,2) These survival differences can partly be explained by different definitions of OHCA,(2) but mainly due to the overall quality of the local Chain of Survival (COS)(3); early arrest recognition and call for help, early CPR, early defibrillation and early post resuscitation care. By identifying and thereafter improving weak links in the local COS, survival can indeed increase. This review will focus on the quality of the last link in the COS, the hospital treatment after return of spontaneuous circulation (ROSC), and how good quality post resuscitation care can improve not only survival, but survival with neurologically intact outcome.
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Basic Life Support has changed significantly over the last 15 years. Evidence-based changes in recommendations involved compression rate, compression depth and the ratio between compressions and ventilations. There is much evidence that early basic life support increases the probability of survival two- to three-fold. ⋯ For those who have been trained in BLS and who are willing to give full CPR, should administer ventilations and chest compressions according to the guidelines. The AED plays a key role in early management of cardiac arrest and can substantially contribute to better survival. Logistics of placement of AEDs and the optimal way to bring AEDs to a victim require much more efforts, especially for victims in residential area's, where the great majority of cases of cardiac arrest occur.
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The best predictor of good outcome after cardiac arrest is awakening from coma. The longer it takes to regain consciousness, the greater the risk of permanent brain injury. A reliable neurological assessment could previously be performed on day 3 after arrest; absence of or a stereotypic motor reaction to pain and absence of cranial nerve reflexes were reliable predictors of poor outcome, but this has changed. ⋯ This is probably due to increased use of sedative drugs and delayed metabolism during hypothermia but could, in addition, be explained by delayed maturation and recovery processes of brain ischaemia. A clinical neurological assessment should no longer be the sole decisive method for prognostication after cardiac arrest. Instead, a clinical investigation should be used in combination with independent and objective methods, above all neurophysiology (electroencephalography and somatosensory evoked potentials), while biomarkers and brain imaging may be valuable adjuncts.
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More than 10 years ago, the randomised studies of therapeutic hypothermia after cardiac arrest showed significant improvement of neurological outcome and survival. Since then, it has become clear that most of the possible adverse events of therapeutic hypothermia are mild and can easily be controlled by proper administration of intensive care. ⋯ Hence, the exact level of target temperature, duration of cooling, rewarming, timing of the therapy and concomitant medication to facilitate therapeutic hypothermia will be important in the future. Additionally, the use of a post-resuscitation treatment bundle (specialised cardiac-arrest centres including intensive post-resuscitation care, appropriate haemodynamic and respiratory management, therapeutic hypothermia and percutaneous coronary intervention) could further improve treatment of cardiac arrest.
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Best Pract Res Clin Anaesthesiol · Sep 2013
ReviewInternational CPR guidelines - perspectives in CPR.
The International Liaison Committee on Resuscitation (ILCOR) co-ordinates regular reviews of cardiopulmonary resuscitation (CPR) science and publishes consensus on science statements and treatment recommendations. These outputs are used by international resuscitation organisations to generate clinical guidelines. This review will outline the history behind the development of international CPR guidelines and will provide a detailed description of the current guideline generating process. A perspective is provided on the future of this process and the prospects for completely unified international CPR guidelines.