Page 694 - ACCCN's Critical Care Nursing

Resuscitation 671

Conflicting evidence exists as to the psychological effects
of such an event on the family. Effects have been docu- BOX 24.1 Cooling techniques postcardiac
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mented as ranging from no adverse effects through to arrest 107-109
expressions of distress, haunting consequences and
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trauma. Where families are provided the option of External:
being present, a staff member should be identified to l Cooling blankets/pads, ice packs, wet towels, fanning and
have sole responsibility of supporting the family. cooling helmets
CEASING CPR Internal:
l IV administration of saline (30 mL/kg at 4°C over 30 minutes
The decision to cease CPR is often difficult; continuing to achieve a 1.5°C fall in core temperature)
CPR beyond 30 minutes without return of spontaneous l IV heart exchange device
circulation (ROSC) is usually futile unless the arrest was l Peritoneal and pleural lavage (not generally used)
compounded by hypothermia, submersion in cold water,
lightning strike, drug overdose or other identified and
treatable conditions such as intermittent VF/VT. Pro-
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longed resuscitation of greater than 60 minutes may be of body temperature, identification and treatment of
made for a severely hypothermic, child victim of near- acute coronary syndromes and optimisation of mechani-
drowning. Pupillary signs should not be used as a predic- cal ventilation are a few of the targeted objectives of care
tor of outcome in infants and children, as 11–33% of (ARC & NZRC Guideline 11.8). 62
children with non-reactive pupils have survived long-
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term after CPR. It is important to have eliminated all ROLE OF HYPOTHERMIA IN ADULTS AFTER
causes as far as possible. CARDIAC ARREST
Termination of resuscitation is a multifactorial process, During cardiac arrest, prolonged global ischaemia
influenced by provider comfort and experience, patient coupled with inadequate reperfusion during the immedi-
prognosis, desires previously expressed, wishes and ate postresuscitation period can lead to severe cerebral
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values, the culture of the hospital, the EMS or emergency hypoxic injury. Induced moderate hypothermia (28–
department, protocols and resource issues, and national 32°C) has been used in open-heart cardiac surgery since
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and international guidelines that reflect changing stan- the 1950s to protect the brain against global ischaemia.
dards of care, resource availability, global interpretations One randomised control trial and other studies have
107
of utility and emerging science. With scientific advances shown that cooling patients postcardiac arrest provides
and evidence-based protocols becoming more widely significant survival benefit as well as improved cardiac
implemented, current impressions of termination deci- and neurological function. 113-115 Prospective randomised
107
sions will change over time. It is appropriate to invite studies have demonstrated that mild hypothermia (32–
suggestions from team members, to ensure that all 34°C) increases the rate of favourable neurological
members are comfortable with a decision to stop the outcome in comatosed adult patients resuscitated after
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resuscitation attempt. Ultimately, terminating CPR is out-of-hospital cardiac arrest (OHCA) due to VF. 114,115 A
equivalent to a determination of death, and must be variety of cooling techniques are described in Box 24.1.
made by a physician. In some out-of-hospital circum- Therapeutic cooling consists of the induction, mainte-
stances it may be the paramedical staff that make this nance and rewarming phases. ILCOR recommends
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decision regarding stopping CPR. Prospectively validated that unconscious adult patients with spontaneous cir-
termination of resuscitation rules such as the ‘basic life culation after OHCA should be cooled to 32–34°C for
support termination of resuscitation rule’ are recom- 12–24 hours if the initial rhythm was VF. This cooling
mended to guide termination of prehospital CPR in may also be beneficial for other rhythms or in-hospital
adults. 24 113
cardiac arrest. It is important to note that shivering
POSTRESUSCITATION PHASE must be prevented during this phase (ARC & NZRC
62
Guideline 11.8).
The aim of postresuscitation care is the maintenance of Persistent hyperglycaemia following cardiac arrest has
cerebral and myocardial perfusion and the return of a been associated with poor neurological outcome. Moni-
patient to a state of best possible health. Resuscitation toring of blood sugar levels and treatment of hypergly-
does not cease with the return of spontaneous circula- caemia (>10 mmol/L) with insulin is recommended in
tion. However, the ROSC after cardiac arrest does not the post cardiac arrest period. 117
always equate to a positive outcome for the patient. Mor-
tality rates following in-hospital cardiac arrests vary NEAR-DEATH EXPERIENCES
between 67 and 71%. 108,109 This high mortality rate has
been attributed to multiple organs that are involved with With the rise in survival rates after a critical illness, there
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whole of body ischaemia during cardiac arrest. The are increasing numbers of documented near-death
reperfusion responses that occur following successful (NDEs) and out-of-body (OBEs) experiences. 118,119 Near-
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resuscitation is termed postcardiac arrest syndrome. death has been described as unusual experiences during
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Coordinated care and specific interventions initiated in a close brush with death. Experiences have typically
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the postarrest phase can influence outcomes. Control included memories of bright tunnels of light, deceased