Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest

Abstract

The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.

Parameters Influencing Brain Oxygen Measurement by Regional Oxygen Saturation in Postcardiac Arrest Patients with Targeted Temperature Management

“…If rSO 2 is measured in patients with a normal or mildly injured brain, rSO 2 should be correlated with SaO 2 , Hb, and PaCO 2 and not with MAP. This could explain Fick's formula (Nakashima et al, 2017) and display normal CVAR (Sundgreen et al, 2001;Brady et al, 2007;Pham et al, 2015). In this study, only patients in the favorable group at 24 hours were followed with this hypothesis.…”

“…CBF is described by the Hagen-Poiseuille's equation: CBF = k · ((MAP-ICP) · d 4 )/(L · l) (k: physical constant, MAP: mean arterial pressure, ICP: intracranial pressure, d: cerebral vessel diameter, l: blood viscosity, L: length of vessel). Cerebral vessel diameter is regulated by arterial carbon dioxide pressure (PaCO 2 ) and l is influenced by Hb (Nakashima et al, 2017). In the standard ICU setting for PCAS patients, parameters such as SaO 2 , Hb, MAP, BT, and PaCO 2 are usually evaluated.…”

The impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients

“…Monitoring of haemodynamic status of patients after CA represents a challenge for the intensivist, as he/she tries to prevent secondary brain damage, which may contribute to further compromise neurological recovery in this setting. 13 No randomised clinical studies are available to help define the optimal haemodynamic strategy to improve neurological outcome after CA, in particular because of the lack of specific goals or targets to individualise treatment. 14 Several studies showed that high lactate levels during the first few hours after ICU admission were predictors of mortality or unfavourable neurological outcome in CA patients.…”

Prognostic Effects of Vasomotor Reactivity during Targeted Temperature Management in Post-Cardiac Arrest Patients: A Retrospective Observational Study

“…Unconsciousness is not only an initial manifestation in post-cardiac arrest syndrome (PCAS), but also a common neurological presentation that persists in intensive care units (ICUs) following resuscitation [ 1 , 2 ]. Brain injury after cardiac arrest is a major factor in determining sustained disability and final mortality of patients with PCAS, which is often terminated by the withdrawal of life-sustaining treatment [ 3 ]. Since the introduction of targeted temperature management (TTM), the timing of the prognosis for patients with comatose PCAS has been conservatively delayed to avoid self-fulfilled prophecy with very early withdrawal of life-sustaining treatment [ 4 , 5 ].…”