Accessibility / Report Error

Results of the implementation of integrated care after cardiorespiratory arrest in a university hospital

ABSTRACT

Objectives:

to identify the care measures performed after cardiorespiratory arrest (CRA) and to relate them to the neurological status and survival at four moments: within the first 24 hours, at the discharge, six months after discharge, and one year after discharge.

Method:

retrospective, analytical and quantitative study performed at the Emergency Department of a university hospital in São Paulo. Eighty-eight medical records of CRA patients who had a return of spontaneous circulation sustained for more than 20 minutes were included and the post-CRA care measures performed in the first 24 hours were identified, as well as its relationship with survival and neurological status.

Results:

the most frequent post-CRA care measures were use of advanced airway access techniques and indwelling bladder catheterization. Patients who had maintained good breathing and circulation, temperature control and who were transferred to intensive care unit had a better survival in the first 24 hours, after six months and one year after discharge. Good neurological status at six months and one year after discharge was associated with non-use of vasoactive drugs and investigation of the causes of the CRA.

Conclusion:

the identification of good practices in post-CRA care may help to reduce the mortality of these individuals and to improve their quality of life.

Descriptors:
Cardiac Arrest; Cardiopulmonary Resuscitation; Assistance; Critical Care; Emergency Medical Services; Nursing

RESUMO

Objetivos:

identificar os cuidados pós-parada cardiorrespiratória (PCR) realizados e relacioná-los com o estado neurológico e a sobrevida nas primeiras 24 horas, na alta, após seis meses e um ano.

Método:

estudo retrospectivo, analítico e quantitativo, realizado no Serviço de Emergência de um hospital universitário em São Paulo. Foram incluídos 88 prontuários de pacientes atendidos em PCR, que apresentaram retorno da circulação espontânea sustentado por mais de 20 minutos e identificados os cuidados pós-PCR realizados nas primeiras 24 horas, como também a relação com a sobrevida e estado neurológico.

Resultados:

os cuidados pós-PCR realizados com maior frequência foram a obtenção de uma via área avançada e passagem de sonda vesical de demora. Para os pacientes que tiveram manutenção de boa respiração e circulação, controle da temperatura e transferência para unidade de terapia intensiva, a sobrevida foi maior nas primeiras 24 horas, após seis meses e um ano da alta. O bom estado neurológico em seis meses e um ano após a alta associou-se a não utilização de drogas vasoativas e à investigação das causas da PCR.

Conclusão:

a identificação das boas práticas em relação aos cuidados pós-PCR pode auxiliar na diminuição da mortalidade destes indivíduos e na melhora da sua qualidade de vida.

Descritores:
Parada Cardíaca; Reanimação Cardiopulmonar; Assistência; Cuidados Críticos; Serviços Médicos de Emergência; Enfermagem.

RESUMEN

Objetivos:

identificar los cuidados pos-parada cardiorrespiratoria (PCR) realizados y relacionarlos con el estado neurológico y la sobrevida en las primeras 24 horas en el alta, después de seis meses y un año.

Método:

estudio retrospectivo, analítico y cuantitativo, realizado en el Servicio de Emergencia, de un hospital universitario en São Paulo. Fueron incluidos 88 prontuarios de pacientes atendidos en PCR, que presentaron retorno de la circulación espontánea sustentado por más de 20 minutos e identificados los cuidados pos-PCR realizados en las primeras 24 horas y la relación con la sobrevida y estado neurológico.

Resultados:

los cuidados pos-PCR realizados con mayor frecuencia fueron la obtención de una vía área avanzada y pasaje de sonda vesical de demora. Los pacientes que tuvieron mantenimiento de buena respiración y circulación, control de la temperatura y transferencia para unidad de terapia intensiva a sobrevida fue mayor en las primeras 24 horas, después de seis meses y un año del alta. El buen estado neurológico en seis meses y un año después del alta se asoció a la no utilización de drogas vasoactivas y la investigación de las causas de la PCR.

Conclusión:

la identificación de las buenas prácticas en relación a los cuidados pos-PCR puede auxiliar en la disminución de la mortalidad de estos individuos y en la mejoría de su calidad de vida.

Descriptores:
Paro Cardiaco; Reanimación Cardiopulmonar; Asistencia; Cuidados Críticos; Servicios Médicos de Urgencia; Enfermería

Introduction

In Brazil, circulatory diseases, including cardiorespiratory arrest (CRA), were the main cause of death in 201111 Vancini-Campanharo CR, Vancini RL, de Lira CA, Lopes MC, Okuno MF, Batista RE, Atallah ÁN, Góis AF. Um ano de seguimento da condição neurológica de pacientes pós-parada cardiorrespiratória atendidos no pronto-socorro de um hospital universitário. 2015 Apr-Jun;13(2):183-8. doi: 10.1590/S1679-45082015AO3286.
https://doi.org/10.1590/S1679-45082015AO...
. A total of 200,000 CRA events are estimated to occur every year, with approximately half occurring in hospital settings22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
.

After the return of spontaneous circulation (RSC), defined as the maintenance of myocardial contractions capable of generating a pulse for more than 20 minutes after the completion of cardiopulmonary resuscitation (CPR), a severe clinical syndrome is started, which is responsible for about from 50 to 70% of deaths in the first 24 to 48 hours after CRA. The post-cardiac arrest syndrome happens due to hypoxia and reperfusion lesions during the CRA and after the RSC33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
-44 Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015 Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015;95:202-22. doi: 10.1007/s00134-015-4051-3.
https://doi.org/10.1007/s00134-015-4051-...
.

Post- care has the potential to improve early mortality rates caused by hemodynamic instability and multiple organ and system failure, and late morbidity and mortality rates resulting from neurological damage. The main goals are to improve cardiopulmonary function and systemic perfusion; transport the CRA victims from out-of-hospital settings to emergency or intensive care units; identify the precipitating cause of the CRA and prevent its recurrence; and implement measures to improve the long-term prognosis of patients and preserve their neurological function33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

The main measures to be adopted include: early reperfusion therapy for cases of coronary thrombosis; stabilization and maintenance of hemodynamic parameters; correction of arterial gas disorders; maintenance of normal glucose values; control of water balance; administration of sedation and analgesia; prevention and treatment of seizures and temperature control22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
-33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

This study is based on the low survival rates found among CRA victims and on the great risk of neurological sequel to which they are exposed when spontaneous circulation returns.

Despite the advances in emergency cardiovascular care, the need for new techniques to reverse the injury of ischemia and reperfusion is evident. In this context, it is vitally important to identify the post-CRA care measures so that strategies may be implemented with the objective of reducing mortality associated with hemodynamic instability, limiting brain damage and injury to other organs.

Thus, the objectives of this study were to identify the post-CRA care measures performed in a university hospital and to relate them to the survival and neurological status of the patients in the first 24 hours, at hospital discharge, six months after discharge, and one year after discharge.

Method

Study approved by the Ethics and Research Committee of the Federal University of São Paulo (CAEE: 52531315.4.0000.5505).

The study had a retrospective, analytical and quantitative approach, and it was carried out in the Emergency Room (ER) of a university hospital in the city of São Paulo (SP), Brazil.

All adult patients who had CRA in out-of-hospital settings and were taken for assistance at the ER of the above mentioned service in the year 2011, and who presented RSC sustained for more than 20 minutes were included in this study, totaling 88 patients. We excluded from this study the CRA cases assisted in other sectors of the hospital.

Data collection was performed in four different moments through the analysis of medical records. At admission, the following variables were collected: age, gender, skin color, presence of comorbidities, previous CRA events, pre-CRA neurological status, presence of consciousness, breathing and pulse at the arrival of the patient in the ER, place where the CRA occurred, if there were witnesses, presumed immediate cause, initial rhythm of CRA and interventions performed during care55 Avansi PA, Meneghin P. Translation and adaptation of the In-Hospital Utstein style into the Portuguese language. Rev Esc Enferm USP. 2008;42(3):504-11. doi: 10.1590/S0080-623420150000500008.
https://doi.org/10.1590/S0080-6234201500...
.

During the first 24 hours; the following post-CRA care measures were identified and recorded: use of advanced airway access techniques; monitoring of respiratory rate; maintenance of respiratory rate between 10 and 12 rpm; monitoring of pulse oximetry; maintenance of oxygen saturation between 94 and 96%; maintenance of CO2 partial pressure between 40 and 45 mmHg; monitoring of capnography; maintenance of end-expiratory CO2 partial pressure between 35 and 40 mmHg; monitoring of noninvasive blood pressure (NIBP); maintenance of systolic blood pressure (SBP) ≥ 90 mmHg; monitoring of invasive blood pressure (IBP); maintenance of mean arterial pressure (MAP) ≥ 65 mmHg; central venous access puncture; monitoring of central venous pressure; maintenance of venous pressure between 8 and 12 mmHg; monitoring of venous oxygen saturation; maintenance venous oxygen saturation > 70%; administration of saline solutions; administration of vasoactive and antiarrhythmic drugs; in case of ventricular fibrillation and pulseless ventricular tachycardia; electrocardiographic tracing; 12-lead electrocardiogram (ECG); primary percutaneous coronary intervention in cases of suspected acute coronary syndrome; realization of echocardiography; identification and treatment of reversible causes of CRA; monitoring of body temperature; prevention of hyperthermia; monitoring of electroencephalogram; administration of anticonvulsants; monitoring of blood glucose; maintenance of glycemia between 144 and 180mg/dl; chest X-ray; control of general exams every six hours; arterial blood gas analysis every six hours; indwelling bladder catheterization; monitoring of urine output; maintenance of urine output between 0.5 and 1 ml/kg/h; use of sedation in case of cognitive dysfunction; introduction of continuous enteral nutrition in the absence of contraindication and transfer to an Intensive Care Unit (ICU)33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

Survival and neurological status of individuals were assessed at hospital discharge, six month later, and one year later and evaluated by the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). The CPC is divided into five categories. Category 1 indicates complete independence and ability to work; Category 2 indicates moderate disability, ability to work part-time and independence for the Activities of Daily Living; Category 3 indicates severe disability and total dependence on the Activities of Daily Living; category 4 indicates persistent vegetative state; and category 5 indicates brain death66 Rittenberger JC, Raina K, Holm MB, Kim YJ, Callaway CW. Association between Cerebral Performance Category, Modified Rankin Scale, and Discharge Disposition after Cardiac Arrest. Resuscitation 2011;82(8):1036-40. doi: 10.1016/j.resuscitation.2011.03.034.
https://doi.org/10.1016/j.resuscitation....
. In this study, patients diagnosed with CPC 1 and 2 were considered to be in good neurological state, and those evaluated and classified as CPC 3, 4 and 5, were in poor neurological state66 Rittenberger JC, Raina K, Holm MB, Kim YJ, Callaway CW. Association between Cerebral Performance Category, Modified Rankin Scale, and Discharge Disposition after Cardiac Arrest. Resuscitation 2011;82(8):1036-40. doi: 10.1016/j.resuscitation.2011.03.034.
https://doi.org/10.1016/j.resuscitation....
.

Data were analyzed in the softwares PSPP and R, version 3.3.1. Mean, standard deviation, median, minimum and maximum values were calculated for the continuous variables, and frequency and percentage for the categorical variables. The non-parametric Kruskal-Wallis test was used to correlate the survival and neurologic status in the first 24 hours, at discharge, six months after discharge, and one year after discharge. The non-parametric Kruskal-Wallis test was used for continuous variables. The Pearson Chi-square test was used relate the response variable with the categorical variables. The level of significance considered in all analyses was 5%.

Results

Demographic and clinical data are presented in Table 1. The mean age was 66.2 years, and there was predominance of white men, presenting at least one previous comorbidity, and independent in the activities of daily living. At admission to ER, most individuals were conscious, breathing, and had circulation.

Table 1
Demographic and clinical characteristics of study patients. São Paulo, SP, Brazil, 2016 (N = 88)

The characteristics of the CRA events and the interventions performed during CPR are presented in Table 2. Most of the events occurred in the hospital, being witnessed by the health team and with an immediate presumed cause of respiratory failure. The most prevalent rhythm was pulseless electrical activity and the most frequent interventions during the care were compressions, ventilation and medication administration.

Table 2
Characteristics of cardiorespiratory arrest events and interventions performed during the care of the study patients. São Paulo, SP, Brazil, 2016 (N = 88)

The mean time between initiation of CPR and the first shock was 7.8 minutes; between the initiation of CPR and installation of advanced airway access was 4.1 minutes; between the initiation of CPR and the first dose of epinephrine was 2.1 minutes; and the mean duration of CPR was 11.1 minutes.

Post-CPR care performed in the first 24 hours after the RSC is shown in Table 3. Of the 88 medical records analyzed, 8 did not contain sufficient information to collect data, totaling 80 charts.

Monitoring of capnography and venous oxygen saturation and electroencephalogram were not performed in any patient.

Table 3
Post-cardiorespiratory care after the first 24 hours in the study patients. São Paulo, SP, Brazil, 2016 (N = 80)

Of the 88 patients surveyed, 13 survived at discharge, 10 after six months, and 9 after one year. The variables that were significantly associated with greater patient survival are presented in Table 4.

Realization of post-CRA care was not associated with greater survival of individuals at hospital discharge.

Table 4
Association of post-cardiorespiratory arrest care with survival of the studied patients in the first 24 hours, six months after discharge, and one year after discharge. São Paulo, SP, Brazil, 2016

When post-CRA care was related to neurological status at discharge, six months after discharge, and one year after discharge, none of the interventions were related to patients’ neurologic status within the first 24 hours or at hospital discharge. However, patients who did not receive vasoactive drugs and underwent investigation of the causes of the CRA presented good neurological status, CPC 1 and 2, in six months (p = 0.04) and one year (p = 0.02) after discharge hospital.

Discussion

According to the guidelines of the American Heart Association, post-CRA care aims to reduce early mortality due to hemodynamic instability and to limit later multiple organ failure and brain injury. This care includes adequate cardiopulmonary conditions and perfusion of vital organs; safe transportation to intensive care units; early recognition of the causes of the event, and treating and preventing its recurrence; controlled temperature to minimize neurological damage; diagnosis and treatment of acute myocardial ischemia; ventilatory support with mechanical ventilation to limit lung injury; reducing the risk of multiple organ failure; assessment of neurological recovery prognosis; and promotion of rehabilitation of survivors33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

The mean age of the patients in this study was 66.2 years, as in a study carried out in Singapore by the National Emergency Ambulance System77 Eng Hock Ong M, Chan YH, Anantharaman V, Lau ST, Lim SH, Seldrup J. Cardiac arrest and resuscitation epidemiology in Singapore (CARE I study). Pre hosp Emerg Care. [Internet]. 2003 [cited 2016 Nov 2];7(4): 427-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14582091.
https://www.ncbi.nlm.nih.gov/pubmed/1458...
. There was a prevalence of conscious, white people, breathing and with pulse at admission, and the predominant rhythm was pulseless electrical activity, a result that is different from that reported in the international literature77 Eng Hock Ong M, Chan YH, Anantharaman V, Lau ST, Lim SH, Seldrup J. Cardiac arrest and resuscitation epidemiology in Singapore (CARE I study). Pre hosp Emerg Care. [Internet]. 2003 [cited 2016 Nov 2];7(4): 427-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14582091.
https://www.ncbi.nlm.nih.gov/pubmed/1458...
. Such findings may be associated with the fact that most events occurred in the in-hospital setting, in more complex patients, and with other associated comorbidities88 Vancini-Campanharo CR, Vancini RL, Lira CAB, Andrade M, Góis AFT, Atallah ANA. Cohort study on the factors associated with survival post-cardiac arrest. Sao Paulo Med J. 2015;133(6):495-501. doi: 10.1590/1516-3180.2015.00472607.
https://doi.org/10.1590/1516-3180.2015.0...
.

In this study, maintenance of systolic blood pressure ≥ 90 mmHg, administration of vasoactive drugs, investigation of causes of the arrest, maintenance of mean arterial pressure ≥ 65 mmHg, 12-lead electrocardiogram, central venous access puncture, crystalloid administration and bladder catheterization were the most frequent care measures. These actions aim at adapting the cardiovascular conditions and organ and system perfusion, since death due to multiple organ failure is associated with a persistent low cardiac output in the first 24 hours after CPR22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
.

Advanced airway access was frequently performed in the patients in this study. In these cases, ventilation and oxygenation should be immediately optimized, thus avoiding hyperoxia, which contributes to an increase in oxidative stress and is associated with a worse neurological prognosis22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
,66 Rittenberger JC, Raina K, Holm MB, Kim YJ, Callaway CW. Association between Cerebral Performance Category, Modified Rankin Scale, and Discharge Disposition after Cardiac Arrest. Resuscitation 2011;82(8):1036-40. doi: 10.1016/j.resuscitation.2011.03.034.
https://doi.org/10.1016/j.resuscitation....
. A study evaluated 173 comatose patients after sudden cardiac arrest and found that those who had lower maximum partial pressure of arterial oxygen in the first 24 hours after cardiac arrest had higher survival rates at discharge compared to the others99 Janz DR, Hollenbeck RD, Pollock JS, McPherson JA, Rice TW. Hyperoxia is Associated with Increased Mortality in Patients Treated with Mild Therapeutic Hypothermia after Sudden Cardiac Arrest. Crit Care Med. 2012;40(12):3135-9. doi: 10.1097/CCM.0b013e3182656976.
https://doi.org/10.1097/CCM.0b013e318265...
. In addition, cerebral vasoconstriction aggravated by hyperventilation potentiates ischemic brain injury1010 Phelps R, Dumas F, Maynard C, Silver J, Rea T. Cerebral performance category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med. 2013;41(5):1252-7. doi: 10.1097/CCM.0b013e31827ca975.
https://doi.org/10.1097/CCM.0b013e31827c...
and reduces cardiac output at the expense of an increase in intrathoracic pressure33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

As for prevention of brain injury, the most frequent care measure in this study was the prevention of hyperthermia and continuous sedation. Studies have shown that patients who reached temperature above 37.6ºC after the return of the spontaneous circulation had lower survival chance and worse neurological prognosis in relation to the normothermic ones33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
. Evidence on prevention of post-CRA hyperthermia is still not well established, but the occurrence of fever is associated with worsening of neurological injury in patients undergoing intensive care for other conditions1111 Bohman LE, Levine JM. Fever and therapeutic normothermia in severe brain injury: an update. Curr Opin Crit Care. 2014;20:182-8. doi: 10.1097/MCC.0000000000000070.
https://doi.org/10.1097/MCC.000000000000...
. Thus, the fight against fever is recommended because of the potential aggravation of ischemic brain damage33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
. Other neuroprotective measures are recommended, such as the prevention of seizures and the continuous monitoring of brain activity through electroencephalogram66 Rittenberger JC, Raina K, Holm MB, Kim YJ, Callaway CW. Association between Cerebral Performance Category, Modified Rankin Scale, and Discharge Disposition after Cardiac Arrest. Resuscitation 2011;82(8):1036-40. doi: 10.1016/j.resuscitation.2011.03.034.
https://doi.org/10.1016/j.resuscitation....
.

When post-CRA care and 24-hour survival were associated, the variables: respiratory rate; oxygen saturation; IBP and NIBP; body temperature; maintenance of oxygen saturation between 94 and 96%; SBP greater than or equal to 90 mmHg; MAP greater than or equal to 65 mmHg; urine output of 0.5-1 ml/kg/min; 12-lead ECG and chest X-ray; indwelling bladder catheterization; continuous sedation; prevention against hyperthermia; and transfer of the patient to the ICU were related to increased survival when performed at intervals of 2 hours or less.

Six months after discharge, maintenance of oxygen saturation between 94 and 96%, non-administration of vasoactive drugs and transfer of the patient to the ICU were related to higher survival rates. In a study performed with out-of-hospital cardiorespiratory arrest patients, it was observed that increased partial oxygen pressure (PaO2), greater than 300 mmHg, during CPR were associated with higher rates of return to spontaneous circulation and better neurological outcomes when compared to normal or lower partial oxygen pressure (PaO2 of less than 60 mmHg)1212 Spindelboeck W, Schindler O, Moser A, Hausler F, Wallner S, Strasser C, Haas J, Gemes G, Prause G. Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission. Resuscitation. 2013;84(6):770-5. doi: 10.1016/j.resuscitation.2013.01.012.
https://doi.org/10.1016/j.resuscitation....
. Prevention of hypoxemia is considered more important than avoiding any potential risk of hyperoxia33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

Regarding the administration of vasoactive drugs, studies evaluating specific strategies to improve blood pressure comparing vasopressors and fluids are scarce. A study performed with patients who achieved a return to spontaneous circulation after CPR found that MAP greater than 70 mmHg in the first 6 hours after CPR was associated with good neurological function1313 Kilgannon JH, Roberts BW, Jones AE, Mittal N, Cohen E, Mitchell J, Chansky ME, Trzeciak S. Arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest*. Crit Care Med. 2014 Sep;42(9):2083-91. doi: 10.1097/CCM.0000000000000406.
https://doi.org/10.1097/CCM.000000000000...
. Although there was no consensus regarding the ideal values ​​of MAP, the importance of strict monitoring to maintain effective circulation is emphasized, mainly in order to avoid hypotension in order to obtain better results after a CRA.

Transfer of post-CRA patients to the ICU may be related to greater survival rates because an ICU is a safer and better treatment environment for critical patients in view of its infrastructure with more advanced materials and equipment, as well as qualified personnel to provide specialized assistance22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
-33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

In this study, at one year after discharge, the variables that were significantly associated with higher survival rates were monitoring of respiratory rate; oxygen saturation; noninvasive blood pressure; electrocardiographic tracing; maintenance of oxygen saturation between 94 and 96%; administration of antiarrhythmic drugs; performance of ECG and referral for hemodynamics in the case of acute coronary syndrome; and transfer of the patient to the ICU. After the RSC, patients have a high probability of developing multiple organ and system failure. Therefore, systemic perfusion should be adequate, metabolic homeostasis should be restored and the function of the various organs should be maintained, aiming to increase survival prospects without neurological damage over time33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
.

Regarding the neurological state of the individuals, those who did not receive vasoactive drugs had a better six-month and one-year neurological prognosis. Brain injury is an important cause of post-CRA morbidity and mortality. Recognition of its pathophysiological mechanisms and its correlation with patient characteristics, CPR maneuvers, and post-CRA care may improve the prognosis of these individuals1414 Cassiani-Miranda CA, Pérez-Aníbal E, Vargas-Hernández MC, Castro-Reyes ED, Osorio AF. Brain injury after cardiac arrest. Acta Neurol Colomb. [Internet]. 2013 [cited 2016 Nov 9];29(4):255-65. Available from: https://www.acnweb.org/es/acta-neurologica/volumen-29-2013/147-volumen-29-no-4/930-lesion-cerebral-posterior-a-paro-cardiorrespiratorio.html
https://www.acnweb.org/es/acta-neurologi...
.

Hemodynamic stabilization, MAP greater than 65 mmHg, can often only be achieved with the use of vasoactive drugs and is critical for effective cerebral circulation after a CRA. Good hemodynamic parameters are related to higher survival rates at hospital discharge and better long-term neurological outcomes33 Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
https://doi.org/10.1161/CIR.000000000000...
. However, further studies on vasoactive drugs are necessary because, depending on the mechanism of action of such drugs, they may lead to changes in peripheral vascular resistance, heart rate, arrhythmias and myocardial ischemia1515 De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779-89. doi: 10.1056/NEJMoa0907118.
https://doi.org/10.1056/NEJMoa0907118...
.

Differential diagnosis of the cause of CRA is paramount for establishing definitive treatment22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
, and in this study, it was related to a higher patient survival at six months and one year after hospital discharge. Detecting the cause of the CRA can be difficult and often implies frequent reassessment of the patient through collection of information, clinical evaluation, blood profile and imaging tests22 Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
https://doi.org/10.5935/abc.20130022...
. More studies on this subject are necessary to elucidate the role of new resources to optimize the diagnosis of the causes of CRA and their reversal, as well as measures to help in the determination of patient prognosis1616 Bouwes A, Binnekade JM, Kuiper MA, Bosch FH, Zandstra DF, Toornvliet AC et al. Prognosis of coma after therapeutic hypothermia: a prospective cohort study. Ann Neurol. 2012;71:206-12. doi: 10.1002/ana.22632.
https://doi.org/10.1002/ana.22632...
.

The main limitation of this study was to have been performed in a single center, which may not represent other realities. In addition, because this was a retrospective study, there were difficulties during collection, such as medical records with incomplete data and difficult to interpret.

CRA is the most severe clinical emergency and with the worse prognosis, but it may be a transient, reversible stage with the possibility of recovery and returning to activities. The identification of post-CRA care in a Brazilian referral hospital can subsidize public policies aimed at the care of these individuals, reducing mortality and limiting the occurrence of neurological damage and functional disability, as well as adding key information for its prognosis and rehabilitation.

Conclusion

The most frequent post-CRA care measures performed in the patients in this study were: use of advanced airway access techniques; indwelling bladder catheterization; maintenance of SBP ≥ 90 mmHg and MAP ≥ 65 mmHg; investigation of the causes of the CRA; and administration of vasoactive drugs.

Survival in the first 24 hours was greater in patients who received the following care measures: maintenance of good breathing and circulation, temperature control, continuous sedation, chest X-ray, and transfer to intensive care unit. After 6 months, survival was significantly greater in cases where oxygen saturation was maintained between 94 and 96%, vasoactive drugs were not administered, and in those patients who were transferred to the ICU. After one year of hospital discharge, maintenance of good breathing and circulation, 12-lead ECG, patient referral for hemodynamic support, and transfer to ICU were the care associated with better patient survival.

Regarding neurological status, patients who did not receive vasoactive drugs and those who had the cause of CRA diagnosed survived with good neurological status at six months and one year after discharge.

References

  • 1
    Vancini-Campanharo CR, Vancini RL, de Lira CA, Lopes MC, Okuno MF, Batista RE, Atallah ÁN, Góis AF. Um ano de seguimento da condição neurológica de pacientes pós-parada cardiorrespiratória atendidos no pronto-socorro de um hospital universitário. 2015 Apr-Jun;13(2):183-8. doi: 10.1590/S1679-45082015AO3286.
    » https://doi.org/10.1590/S1679-45082015AO3286
  • 2
    Gonzalez MM, Timerman S, Oliveira RG, Polastri TF, Dallan LAP, Araujo S, et al. I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo. ArqBrasCardiol. 2013;100(2):105-13. doi: 10.5935/abc.20130022.
    » https://doi.org/10.5935/abc.20130022
  • 3
    Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl2):465-82. doi: 10.1161/CIR.0000000000000262
    » https://doi.org/10.1161/CIR.0000000000000262
  • 4
    Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015 Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015;95:202-22. doi: 10.1007/s00134-015-4051-3.
    » https://doi.org/10.1007/s00134-015-4051-3
  • 5
    Avansi PA, Meneghin P. Translation and adaptation of the In-Hospital Utstein style into the Portuguese language. Rev Esc Enferm USP. 2008;42(3):504-11. doi: 10.1590/S0080-623420150000500008.
    » https://doi.org/10.1590/S0080-623420150000500008
  • 6
    Rittenberger JC, Raina K, Holm MB, Kim YJ, Callaway CW. Association between Cerebral Performance Category, Modified Rankin Scale, and Discharge Disposition after Cardiac Arrest. Resuscitation 2011;82(8):1036-40. doi: 10.1016/j.resuscitation.2011.03.034.
    » https://doi.org/10.1016/j.resuscitation.2011.03.034
  • 7
    Eng Hock Ong M, Chan YH, Anantharaman V, Lau ST, Lim SH, Seldrup J. Cardiac arrest and resuscitation epidemiology in Singapore (CARE I study). Pre hosp Emerg Care. [Internet]. 2003 [cited 2016 Nov 2];7(4): 427-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14582091
    » https://www.ncbi.nlm.nih.gov/pubmed/14582091
  • 8
    Vancini-Campanharo CR, Vancini RL, Lira CAB, Andrade M, Góis AFT, Atallah ANA. Cohort study on the factors associated with survival post-cardiac arrest. Sao Paulo Med J. 2015;133(6):495-501. doi: 10.1590/1516-3180.2015.00472607.
    » https://doi.org/10.1590/1516-3180.2015.00472607
  • 9
    Janz DR, Hollenbeck RD, Pollock JS, McPherson JA, Rice TW. Hyperoxia is Associated with Increased Mortality in Patients Treated with Mild Therapeutic Hypothermia after Sudden Cardiac Arrest. Crit Care Med. 2012;40(12):3135-9. doi: 10.1097/CCM.0b013e3182656976.
    » https://doi.org/10.1097/CCM.0b013e3182656976
  • 10
    Phelps R, Dumas F, Maynard C, Silver J, Rea T. Cerebral performance category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med. 2013;41(5):1252-7. doi: 10.1097/CCM.0b013e31827ca975.
    » https://doi.org/10.1097/CCM.0b013e31827ca975
  • 11
    Bohman LE, Levine JM. Fever and therapeutic normothermia in severe brain injury: an update. Curr Opin Crit Care. 2014;20:182-8. doi: 10.1097/MCC.0000000000000070.
    » https://doi.org/10.1097/MCC.0000000000000070
  • 12
    Spindelboeck W, Schindler O, Moser A, Hausler F, Wallner S, Strasser C, Haas J, Gemes G, Prause G. Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission. Resuscitation. 2013;84(6):770-5. doi: 10.1016/j.resuscitation.2013.01.012.
    » https://doi.org/10.1016/j.resuscitation.2013.01.012
  • 13
    Kilgannon JH, Roberts BW, Jones AE, Mittal N, Cohen E, Mitchell J, Chansky ME, Trzeciak S. Arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest*. Crit Care Med. 2014 Sep;42(9):2083-91. doi: 10.1097/CCM.0000000000000406.
    » https://doi.org/10.1097/CCM.0000000000000406
  • 14
    Cassiani-Miranda CA, Pérez-Aníbal E, Vargas-Hernández MC, Castro-Reyes ED, Osorio AF. Brain injury after cardiac arrest. Acta Neurol Colomb. [Internet]. 2013 [cited 2016 Nov 9];29(4):255-65. Available from: https://www.acnweb.org/es/acta-neurologica/volumen-29-2013/147-volumen-29-no-4/930-lesion-cerebral-posterior-a-paro-cardiorrespiratorio.html
    » https://www.acnweb.org/es/acta-neurologica/volumen-29-2013/147-volumen-29-no-4/930-lesion-cerebral-posterior-a-paro-cardiorrespiratorio.html
  • 15
    De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779-89. doi: 10.1056/NEJMoa0907118.
    » https://doi.org/10.1056/NEJMoa0907118
  • 16
    Bouwes A, Binnekade JM, Kuiper MA, Bosch FH, Zandstra DF, Toornvliet AC et al. Prognosis of coma after therapeutic hypothermia: a prospective cohort study. Ann Neurol. 2012;71:206-12. doi: 10.1002/ana.22632.
    » https://doi.org/10.1002/ana.22632

Publication Dates

  • Publication in this collection
    2018

History

  • Received
    01 June 2017
  • Accepted
    26 Nov 2017
Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br