Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

Neurocritical Care · 24 authors, 24 centres

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TL;DR

This scientific statement provides consensus-based guidance for the critical care management of adult survivors of cardiac arrest, addressing multiple organ systems including neurological, cardiac, pulmonary, hematologic, infectious, endocrine, and gastrointestinal care. Key recommendations include targeting a mean arterial pressure >80 mm Hg when advanced cerebral monitoring is not available, using lung-protective ventilation, and initiating enteral nutrition early. The statement emphasizes the need for individualized, protocol-guided, multidisciplinary care and identifies numerous knowledge gaps requiring further research.

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**Background:** Cardiac arrest (CA) affects over 600,000 people annually in the United States, with overall survival to hospital discharge of 9% for out-of-hospital CA and 23% for in-hospital CA. Achieving return of spontaneous circulation (ROSC) is only the beginning of comprehensive, multisystem care, as most survivors remain unresponsive due to significant brain injury. Current guidelines provide few strong recommendations for post-CA care due to limited evidence, leading to wide variations in clinical practice. This scientific statement was developed by the American Heart Association and Neurocritical Care Society to address knowledge gaps and provide clinical guidance on topics where research and existing guidelines could not provide high certainty of evidence.

**Methods:** A multidisciplinary panel of experts was convened, including specialists from neurology, emergency medicine, cardiology, pulmonary, and intensive care, as well as nurses, pharmacists, and respiratory therapists. Topics were organized by organ system: neurological (brain oxygenation/perfusion/edema/ICP, seizures/ictal-interictal continuum, sedation/analgesia), cardiac, pulmonary, hematology, infectious disease, gastrointestinal, endocrine, fluids management, and general critical care. The panel used a modified Delphi approach to achieve consensus, with statements requiring >80% agreement among voting panelists. Literature searches were performed for each topic, and statements were refined through multiple voting cycles.

**Key Results:** The statement presents consensus statements across all organ systems. For neurological management, the panel recommends optimizing cerebral oxygen delivery by maintaining optimal cerebral perfusion pressure, arterial normocapnia, and adequate arterial oxygen content while avoiding hyperoxemia. In ICUs without advanced cerebral monitoring, target mean arterial pressure (MAP) >80 mm Hg is recommended. For seizures, continuous EEG monitoring for 72-120 hours is advised in patients who fail to recover consciousness, with valproic acid and levetiracetam as reasonable first-line agents. For sedation, short-acting agents (propofol, remifentanil, fentanyl) are preferred over midazolam and morphine. For cardiac management, echocardiography should be performed as soon as possible, and early coronary angiography may benefit patients without ST-segment elevation by potentially salvaging myocardium. For pulmonary management, lung-protective ventilation is standard, with FiO2 titrated to achieve SpO2 of 92-98% and Paco2 targeted at 35-45 mm Hg. For hematologic management, red blood cell transfusion is recommended when hemoglobin <7 g/dL, with higher thresholds (<9 g/dL) for acute coronary disease. Deep vein thrombosis prophylaxis should be initiated within 48 hours. For infectious disease, empirical antibiotics may be used in patients treated with hypothermic temperature control to reduce pneumonia incidence. For endocrine and fluids management, glucose targets of 81-180 mg/dL are recommended, and sodium bicarbonate should not be used routinely. The statement also emphasizes protocol-guided care, family support, and team-based care, recommending structured treatment protocols with input from multiple disciplines.

**Clinical Implications:** This scientific statement provides practical, consensus-based guidance for clinicians managing post-cardiac arrest patients in the ICU, addressing critical gaps where high-certainty evidence is lacking. The recommendations emphasize individualized, multimodal monitoring and treatment approaches, particularly for neurological and hemodynamic management. The statement highlights the importance of protocol-guided, multidisciplinary care and identifies numerous areas for future research, including optimal blood pressure targets, seizure management, mechanical circulatory support, and systems of care. By standardizing care and reducing practice variability, these consensus statements aim to improve outcomes for this complex patient population.

STUDY TYPE

guidelines

SPECIALTY

cardiology

SUMMARISED BY

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92% · A

ORIGINAL PAPER

PMC10861627

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

Neurocritical Care

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ABSTRACT

Abstract The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest. Keywords: AHA scientific statements; Critical care; Heart arrest; Hypoxia–ischemia, brain; Resuscitation; Shock, cardiogenic

CITATION EXPORT

Karen G Hirsch, Benjamin S Abella, Edilberto Amorim et al.. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocritical Care. (2023). https://doi.org/10.1007/s12028-023-01871-6

AUTHORS

24 · 24 CENTRES

Karen G Hirsch, Benjamin S Abella, Edilberto Amorim, Mary Kay Bader, Jeffrey F Barletta, Katherine Berg, Clifton W Callaway, Hans Friberg, Emily J Gilmore, David M Greer, Karl B Kern, Sarah Livesay, Teresa L May, Robert W Neumar, Jerry P Nolan, Mauro Oddo, Mary Ann Peberdy, Samuel M Poloyac, David Seder, Fabio Silvio Taccone, Anezi Uzendu, Brian Walsh, Janice L Zimmerman, Romergryko G Geocadin

1Stanford University, Stanford, USA
2University of Pennsylvania, Philadelphia, USA
3San Francisco–Weill Institute for Neurosciences, University of California, San Francisco, USA
4Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
5Midwestern University, Downers Grove, USA
6Beth Israel Deaconess Medical Center, Boston, USA
7University of Pittsburgh, Pittsburgh, USA
8Skane University Hospital, Malmö, Sweden
9Yale University School of Medicine, New Haven, USA
10Boston University School of Medicine, Boston, USA
11Sarver Heart Center, University of Arizona, Tucson, USA
12Rush University College of Nursing, Chicago, USA
13Maine Medical Center, Portland, USA
14University of Michigan, Ann Arbor, USA
15Warwick Medical School, University of Warwick, Coventry, UK
16Royal United Hospital, Bath, UK
17CHUV-Lausanne University Hospital, Lausanne, Switzerland
18Virginia Commonwealth University, Richmond, USA
19University of Texas at Austin, Austin, USA
20Hopital Universitaire de Bruxelles, Brussels, Belgium
21St. Luke’s Mid America Heart Institute, Kansas City, USA
22University of Texas Medical Branch School of Health Sciences, Galveston, USA
23The Methodist Hospital Physician Organization, Houston, USA
24Johns Hopkins University School of Medicine, Baltimore, USA