The New ILCOR Guidelines 2024

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation 2024 Ahead of Print. https://doi.org/10.1016/j.resuscitation.2024.110414.

There are multiple recommendations made in both Basic Life Support(BLS) and Advanced Life Support(ALS). Below we will concentrate on just a few areas of ALS recommendations. 

ADVANCED LIFE SUPPORT

Post–cardiac arrest oxygenation and ventilation

Not much has changed here.

Oxygen Targets (1-5)

• Use 100% inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably in adults with ROSC after cardiac arrest in the prehospital setting (strong recommendation, moderate-certainty evidence) and in-hospital setting (strong recommendation, low-certainty evidence).
• Avoid hypoxemia in adults with ROSC after cardiac arrest in any setting (strong recommendation, very low–certainty evidence).
• Avoiding hyperoxemia in adults with ROSC after cardiac arrest in any setting (weak recommendation, low-certainty evidence).
• Aim for oxygen saturation of 94% to 98% or a partial pressure of arterial oxygen of 75 to 100 mm Hg in adults with ROSC after cardiac arrest in any setting.
  • The EXACT Trial had patients randomised on average at 50 minutes post ROSC, into one of two oxygenation groups:
    1. SpO2 90-94%
    2. SpO2 96-98%

    Primary outcome was survival to hospital discharge. This was lower in the lower oxygen titration group (90–94%). The restrictive group experienced hypoxia in some of their patients requiring 100% oxygen, to re-establish adequate saturations.

Carbon Dioxide Targets

• Aim for normocapnia (35–45 mm Hg or ≈4.7–6.0 kPa) in adults with ROSC, unless higher or lower values are needed to compensate for other illnesses such as lung injury or metabolic acidosis.

Post–cardiac arrest hemodynamics (6-10)

There is a recommendation, (not in the previous 2015 guidelines) for a mean arterial blood pressure (MAP) of at least 60 to 65 mm Hg in patients after cardiac arrest. This is a recommendation as none of the RCTs looked at identified an optimal blood pressure. The value comes from the sepsis literature.

No statistically significant benefit or harm was found from from targeting a higher MAP. In some cases MAP targets of 80 – 100 mm Hg have bee used for some patients , however effectiveness of these higher MAPs have not been confirmed by trials.

How might we judge if a patient requires a higher blood pressure target? Consider the following:

• What is the patients blood pressure status pre arrest? If the patient is usually hypertensive, then it might be reasonable to run a higher MAP.
• If there is evidence of hypoperfusion with the MAP running ie.,
  • low urine output
  • lactate clearance
  • capillary refill

Post–cardiac arrest temperature control (11-16)

6 new trials have been added to the original 32 trials in this area.

The aim now is normal temperature, rather than strict parameters. The one strict recommendation isaActive prevention of fever by targeting a temperature ≤37.5◦C for at least 72 hours for patients who are comatose post ROSC from cardiac arrest

Comatose patients with mild hypothermia should not be actively warmed to a normal temperature.

There is a recommendation against the routine use of prehospital cooling with cold intravenous fluid immediately after ROSC.

Post–cardiac arrest seizure prophylaxis and management

“We suggest against the use of prophylactic antiseizure medication in post–cardiac arrest adults (weak recommendation, very low–certainty evidence).”

One of the thoughts here was that, many sedated patients are either on benzodiazepine or propofol infusions, if sedated post ROSC. These have anti-seizure properties.

Use of advanced airway during cardiac arrest

Bag-mask ventilation or an advanced airway are recommended.

For patients requiring a advanced airway, a supraglottic airway for adults is recommended in OHCA and where there may be a low success rate of tracheal intubation. Tracheal intubation can occur where there is a high success rate.

Studies found that:

• There was no significant difference between tracheal tube and iGel.
• In all five observational studies that compared video with direct laryngoscopy, video laryngoscopy was associated with either better or equivalent outcomes, which ranged from  glottic view to hospital survival).

Antiarrhythmics during and after cardiac arrest

There are no new changes here since 2018.

• Amiodarone or lignocaine is recommended in adults with shock refractory VF/pVT
• Routine use of magnesium in adults with shock-refractory VF/pVT isw not recommended
• Prophylactic antiarrhythmics immediately after ROSC in adults with VF/pVT cardiac arrest are currently not recommended.
• Early administration of antiarrhythmics during cardiac arrest is recommended,  as survival decreased with longer times administration in trials.

References

1. Bernard SA, et al. EXACT Investigators. Effect of lower vs higher oxygen saturation targets on survival to hospital discharge among patients resuscitated after out-of-hospital cardiac arrest: the EXACT randomized clinical trial. JAMA. 2022;328:1818–1826. https://doi.org/10.1001/jama.2022.17701.
2. Moon SW, et al. Arterial minus end-tidal CO2 as a prognostic factor of hospital survival in patients resuscitated from cardiac arrest. Resuscitation. 2007;72:219–225. https://doi.org/10.1016/j.resuscitation.2006.06.034.
3. Mueller M, et al. The difference between arterial pCO(2) and etCO(2) after cardiac arrest – outcome predictor or marker of unfavorable resuscitation circumstances? Am J Emerg Med. 2022;61:120–126. https://doi.org/ 10.1016/j.ajem.2022.08.058.
4. Kim YW, et al. The gradient between arterial and end-tidal carbon dioxide predicts in-hospital mortality in post-cardiac arrest patient. Am J Emerg Med. 2019;37:1–4. https://doi.org/10.1016/j.ajem.2018.04.025.
5. Abrahamowicz AA, et al. The association between arterial-end-tidal carbon dioxide difference and outcomes after out-of-hospital cardiac arrest. Resuscitation. 2022;181:3–9. https://doi.org/10.1016/j. resuscitation.2022.09.019.
6. Niemela V, et al. Higher versus lower blood pressure targets after cardiac arrest: systematic review with individual patient data meta-analysis. Resuscitation. 2023;189, 109862. https://doi.org/10.1016/j.resuscitation.2023.109862
7. Ameloot K, De Deyne C, Eertmans W, et al. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial. Eur Heart J. 2019;40:1804–1814. https://doi.org/10.1093/eurheartj/ehz120.
8. Grand J, Meyer AS, Kjaergaard J, et al. A randomised double-blind pilot trial comparing a mean arterial pressure target of 65 mm Hg versus 72 mm Hg after out- of-hospital cardiac arrest. Eur Heart J Acute Cardiovasc Care. 2020;9:S100–S109. https://doi.org/10.1177/2048872619900095.
9. Jakkula P, Pettila V, Skrifvars MB, et al. COMACARE study group. Targeting low- normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial. Intensive Care Med. 2018;44:2091–2101. https://doi.org/10.1007/s00134-018-5446-8.
10. Kjaergaard J, Moller JE, Schmidt H, et al. Blood-pressure targets in comatose survivors of cardiac arrest. N Engl J Med. 2022;387:1456–1466. https://doi.org/10.1056/NEJMoa2208687.
11. Bernard SA, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–563. https://doi.org/10.1056/NEJMoa003289.
12. N Engl J Med. 2002;346:549–556. https://doi.org/10.1056/NEJMoa012689.
13. Laurent I, et al. High-volume hemofiltration after out-of-hospital cardiac arrest: a randomized study. J Am Coll Cardiol. 2005;46:432–437. https://doi.org/10.1016/j.jacc.2005.04.039.
14. Lascarrou JB, Merdji H, Le Gouge A, et al. Targeted temperature management for cardiac arrest with nonshockable rhythm. N Engl J Med. 2019;381:2327–2337. https://doi.org/10.1056/NEJMoa1906661.
15. Dankiewicz J,  et al. TTM2 Trial Investigators. Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med. 2021;384:2283–2294. https://doi.org/10.1056/NEJMoa2100591.
16. Wolfrum S, Roedl K, Hanebutte A, et al. Hypothermia After In-Hospital Cardiac Arrest Study Group. Temperature control after in-hospital cardiac arrest: a randomized clinical trial. Circulation. 2022;146:1357–1366. https://doi.org/ 10.1161/CIRCULATIONAHA.122.060106.