European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care.

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care.

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

Cognitive impairments and subjective cognitive complaints after survival of cardiac arrest: A prospective longitudinal cohort study.

BACKGROUND: Cardiac arrest can lead to hypoxic brain injury, which can affect cognitive functioning. OBJECTIVE: To investigate the course of objective and subjective cognitive functioning and their association during the first year after cardiac arrest. METHODS: A multi-centre prospective longitudinal cohort study with one year follow-up (measurements at two weeks, three months and one year). Cognitive functioning was measured with a neuropsychological test battery and subjective cognitive functioning with the Cognitive Failures Questionnaire. RESULTS: 141 cardiac arrest survivors participated. Two weeks post cardiac arrest 16% to 29% of survivors were cognitively impaired varying on the different tests, at three months between 9% and 23% and at one year 10%-22% remained impaired with executive functioning being affected most. Significant reduction of cognitive impairments was seen for all tests, with most recovery during the first three months after cardiac arrest. Subjective cognitive complaints were present at two weeks after cardiac arrest in 11%, 12% at three months and 14% at one year. There were no significant associations between cognitive impairments and cognitive complaints at any time point. CONCLUSIONS: Cognitive impairments are common in cardiac arrest survivors with executive functioning being mostly affected. Most recovery is seen in the first three months after cardiac arrest. After one year, a substantial number of patients remain impaired, especially in executive functioning. Because of absence of associations between impairments and complaints, cognitive testing using a sensitive test battery is important and should be part of routine follow-up after a cardiac arrest.

Long-term Outcome After Survival of a Cardiac Arrest: A Prospective Longitudinal Cohort Study.

BACKGROUND: A cardiac arrest can lead to hypoxic brain injury, which can affect all levels of functioning. OBJECTIVE: To investigate 1-year outcome and the pattern of recovery after surviving a cardiac arrest. METHODS: This was a multicenter, prospective longitudinal cohort study with 1 year of follow-up (measurements 2 weeks, 3 months, 1 year). On function level, physical/cardiac function (New York Heart Association Classification), cognition (Cognitive Log [Cog-log], Cognitive Failures Questionnaire), emotional functioning (Hospital Anxiety and Depression Scale, Impact of Event Scale), and fatigue (Fatigue Severity Scale) were assessed. In addition, level of activities (Frenchay Activities Index, FAI), participation (Community Integration Questionnaire [CIQ] and return to work), and quality of life (EuroQol 5D, EuroQol Visual Analogue Scale, SF-36, Quality of Life after Brain Injury) were measured. RESULTS: In this cohort, 141 cardiac arrest survivors were included. At 1 year, 14 (13%) survivors scored below cutoff on the Cog-log. Both anxiety and depression were present in 16 (15%) survivors, 29 (28%) experienced posttraumatic stress symptoms and 55 (52%), severe fatigue. Scores on the FAI and the CIQ were, on average, respectively 96% and 92% of the prearrest scores. Of those previously working, 41 (72%) had returned to work. Most recovery of cognitive function and quality of life occurred within the first 3 months, with further improvement on some domains of quality of life up to 12 months. CONCLUSIONS: Overall, long-term outcome in terms of activities, participation, and quality of life after cardiac arrest is reassuring. Nevertheless, fatigue is common; problems with cognition and emotions occur; and return to work can be at risk.

Early neurologically focused follow-up after cardiac arrest is cost-effective: A trial-based economic evaluation.

OBJECTIVE: To evaluate the cost-effectiveness of an early intervention service for cardiac arrest survivors called 'Stand still …, and move on' from a societal perspective. INTERVENTION: This concise nursing intervention consists of screening for cognitive and emotional problems, information provision and support, self-management promotion, and further referral if necessary. Earlier research confirmed the feasibility of the intervention and its effectiveness in improving emotional functioning and quality of life. METHODS: In this multicentre randomized controlled trial with one year follow-up 185 patients were included between April 2007 and December 2010. The experimental group received the intervention, the control group received care-as-usual. Intervention costs, other direct healthcare costs (e.g. hospital care, rehabilitation, medication, home care) and indirect costs (productivity loss) were measured during ten months using monthly cost-diaries. The economic evaluation comprised a cost-utility analysis (SF-36) and a cost-effectiveness analysis (QOLIBRI) using bootstrapping (5000 replications) to quantify uncertainty concerning the incremental cost effectiveness ratio (ICER), and the probability of the intervention being cost-effective was estimated. To check the robustness of the findings, two sensitivity analyses were performed using the EQ-5D and the complete cases respectively. RESULTS: Of 136 (74%) participants sufficient data concerning costs were collected to be included in this economic evaluation. Intervention costs were on average €127 (SD 85). No significant differences between groups were found with regard to overall costs. The ICERs of the cost-utility and the cost-effectiveness analyses supported the cost-effectiveness of the intervention. The probability of the intervention being cost-effective was 54-76% for the SF-36 and 94% for the QOLIBRI. Findings were robust. CONCLUSION: The intervention 'Stand still …, and move on' has positive societal economic effects and has a high probability to be cost-effective. Implementation in regular healthcare is recommended. TRIAL REGISTRATION: ISRCTN74835019.

European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.

The European Resuscitation Council and the European Society of Intensive Care Medicine have collaborated to produce these post-resuscitation care guidelines, which are based on the 2015 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. Recent changes in post-resuscitation care include: (a) greater emphasis on the need for urgent coronary catheterisation and percutaneous coronary intervention following out-of-hospital cardiac arrest of likely cardiac cause; (b) targeted temperature management remains important but there is now an option to target a temperature of 36 °C instead of the previously recommended 32-34 °C; (c) prognostication is now undertaken using a multimodal strategy and there is emphasis on allowing sufficient time for neurological recovery and to enable sedatives to be cleared; (d) increased emphasis on rehabilitation after survival from a cardiac arrest.

Early neurologically-focused follow-up after cardiac arrest improves quality of life at one year: A randomised controlled trial.

BACKGROUND: Survivors of a cardiac arrest frequently have cognitive and emotional problems and their quality of life is at risk. We developed a brief nursing intervention to detect cognitive and emotional problems, provide information and support, promote self-management, and refer them to specialised care if necessary. This study examined its effectiveness. METHODS: Multicentre randomised controlled trial with measurements at two weeks, three months and twelve months after cardiac arrest. 185 adult cardiac arrest survivors and 155 caregivers participated. Primary outcome measures were societal participation and quality of life of the survivors at one year. Secondary outcomes were the patient's cognitive functioning, emotional state, extended daily activities and return to work, and the caregiver's well-being. Data were analysed using 'intention to treat' linear mixed model analyses. RESULTS: After one year, patients in the intervention group had a significantly better quality of life on SF-36 domains Role Emotional (estimated mean differences (EMD)=16.38, p=0.006), Mental Health (EMD=6.87, p=0.003) and General Health (EMD=8.07, p=0.010), but there was no significant difference with regard to societal participation. On the secondary outcome measures, survivors scored significantly better on overall emotional state (HADS total, EMD=-3.25, p=0.002) and anxiety (HADS anxiety, EMD=-1.79, p=0.001) at one year. Furthermore, at three months more people were back at work (50% versus 21%, p=0.006). No significant differences were found for caregiver outcomes. CONCLUSION: The outcomes of cardiac arrest survivors can be improved by an intervention focused on detecting and managing the cognitive and emotional consequences of a cardiac arrest. TRIAL REGISTRATION: Current controlled trials, ISRCTN74835019.

'Stand still , and move on' , an early neurologically-focused follow-up for cardiac arrest survivors and their caregivers: a process evaluation.

BACKGROUND: A cardiac arrest can lead to hypoxic-ischaemic brain injury which can result in cognitive and emotional impairments and may negatively affect daily functioning, participation in society and quality of life. Furthermore, the impact on the family of the patient can be high. We designed an intervention called 'Stand still …, and move on', which is a concise, individualised, semi-structured intervention for survivors of cardiac arrest and their caregivers, consisting of between one and six face-to-face consultations provided by a trained nurse. The intervention is directed at early detection of cognitive and emotional problems, provision of information, promotion of self-management and referral to specialised care if necessary. The effectiveness of the intervention is being examined in a randomised controlled trial [ISRCTN74835019]. Alongside this trial we performed a process evaluation which aims to investigate the feasibility of the intervention by assessing: 1) the attendance and dose delivered; 2) performance according to protocol; and 3) the opinion of patients, caregivers and nurses on the intervention. METHODS: Participants of this process evaluation were 97 patients allocated to the intervention group of the RCT, their 91 caregivers, and six nurses who conducted the intervention. Measurement instruments used were evaluation forms for patients and caregivers, registration and evaluation forms for nurses, and semi-structured interviews with nurses. RESULTS: Seventy-nine of the patients (81%) allocated to the intervention group and 65 caregivers (71%) participated in the intervention. The mean (SD) number of consultations per patient was 1.8 (1.0), and most consultations were conducted at the patients' home. The intervention was performed largely according to protocol, except that the intervention usually started later than intended, consultations were longer than expected, and the topic of self-management was not regularly addressed. Patients marked the quality of the intervention with a mean score of 7.5 and the performance of the nurse with an 8.0 out of ten. Overall, the intervention was positively evaluated by patients, caregivers and nurses. CONCLUSIONS: The intervention 'Stand still …, and move on' is a promising intervention which was performed largely according to protocol and seems feasible for implementation after some adaptations, if it is found to be effective.

The role of deliberate practice in the acquisition of clinical skills.

BACKGROUND: The role of deliberate practice in medical students' development from novice to expert was examined for preclinical skill training. METHODS: Students in years 1-3 completed 34 Likert type items, adapted from a questionnaire about the use of deliberate practice in cognitive learning. Exploratory factor analysis and reliability analysis were used to validate the questionnaire. Analysis of variance examined differences between years and regression analysis the relationship between deliberate practice and skill test results. RESULTS: 875 students participated (90%). Factor analysis yielded four factors: planning, concentration/dedication, repetition/revision, study style/self reflection. Student scores on 'Planning' increased over time, score on sub-scale 'repetition/revision' decreased. Student results on the clinical skill test correlated positively with scores on subscales 'planning' and 'concentration/dedication' in years 1 and 3, and with scores on subscale 'repetition/revision' in year 1. CONCLUSIONS: The positive effects on test results suggest that the role of deliberate practice in medical education merits further study. The cross-sectional design is a limitation, the large representative sample a strength of the study. The vanishing effect of repetition/revision may be attributable to inadequate feedback. Deliberate practice advocates sustained practice to address weaknesses, identified by (self-)assessment and stimulated by feedback. Further studies should use a longitudinal prospective design and extend the scope to expertise development during residency and beyond.

Determinants of quality of life in survivors of cardiac arrest.

OBJECTIVE: To study factors related to quality of life after a hypoxic period due to cardiac arrest. DESIGN: Retrospective cohort study. SUBJECTS: Eighty-eight survivors of out-of-hospital cardiac arrest, admitted to a Dutch academic hospital between 2001 and 2006. METHODS: Patients received a set of questionnaires at home. The main outcome measures were physical and mental quality of life (Medical Outcomes Study 36-item Short Form Health Survey; SF-36). Potential determinants were cognitive complaints, emotional problems depression/anxiety), post-traumatic stress, fatigue, daily functioning and participation in society. Multiple linear regression analyses were performed with physical and mental quality of life as dependent variables. RESULTS: Sixty-three (72%) patients responded. Mean time since cardiac arrest was 36 months (standard deviation (SD) 19). Backward regression analyses showed that physical quality of life was significantly (p < 0.001, adjusted R2 = 0.531) related to cognitive complaints (beta = -0.378), instrumental daily life activities (beta = 0.262), post-traumatic stress (beta = -0.246) and fatigue (beta = -0.226). Mental quality of life was significantly (p < 0.001, adjusted R2 = 0.664) explained by anxiety/depression (beta = -0.609), fatigue (beta = -0.177) and cognitive complaints (beta = -0.175). CONCLUSION: Quality of life is related to cognitive complaints, fatigue, anxiety/depression, post-traumatic stress and difficulties in daily activities in survivors of out-of-hospital cardiac arrest. Rehabilitation programmes for this group should specifically address these topics.

Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review.

OBJECTIVE: To describe the current evidence on the frequency and nature of cognitive impairments in survivors of out-of-hospital cardiac arrest. DESIGN: Systematic review. DATA SOURCES: Pubmed, Embase, PsychInfo and Cinahl (1980-2006). No language restriction was imposed. REVIEW METHODS: The following inclusion criteria were used: participants had to be survivors of out-of-hospital cardiac arrest, 18 years or older, and there had to be least one cognitive outcome measure with a follow-up of 3 months or more. Case reports and qualitative studies were excluded. The articles were screened on title, abstract and full text by two reviewers. All selected articles were reviewed and assessed by two reviewers independently using a quality criteria list. RESULTS: Out of the 286 articles initially identified, 28 were selected for final evaluation. There was a high heterogeneity between the studies with regard to study design, number of participants, outcome measures and duration of follow-up. In general, the quality of the articles appeared low, with a few positive exceptions. The reported frequency of cognitive impairments in survivors of out-of-hospital cardiac arrest ranged from 6% to 100%. Memory problems were the most common cognitive impairment, followed by impairments in attention and executive functioning. Three high-quality prospective studies found that cognitive problems occurred in about half of the survivors of out-of-hospital cardiac arrest. CONCLUSION: There are few good studies on the frequency of cognitive impairments after out-of-hospital cardiac arrest. However, cognitive problems, in particular memory problems, seem common in survivors of out-of-hospital cardiac arrest.

Activity and Life After Survival of a Cardiac Arrest (ALASCA) and the effectiveness of an early intervention service: design of a randomised controlled trial.

BACKGROUND: Cardiac arrest survivors may experience hypoxic brain injury that results in cognitive impairments which frequently remain unrecognised. This may lead to limitations in daily activities and participation in society, a decreased quality of life for the patient, and a high strain for the caregiver. Publications about interventions directed at improving quality of life after survival of a cardiac arrest are scarce. Therefore, evidence about effective rehabilitation programmes for cardiac arrest survivors is urgently needed. This paper presents the design of the ALASCA (Activity and Life After Survival of a Cardiac Arrest) trial, a randomised, controlled clinical trial to evaluate the effects of a new early intervention service for survivors of a cardiac arrest and their caregivers. METHODS/DESIGN: The study population comprises all people who survive two weeks after a cardiac arrest and are admitted to one of the participating hospitals in the Southern part of the Netherlands. In a two-group randomised, controlled clinical trial, half of the participants will receive an early intervention service. The early intervention service consists of several consultations with a specialised nurse for the patient and their caregiver during the first three months after the cardiac arrest. The intervention is directed at screening for cognitive problems, provision of informational, emotional and practical support, and stimulating self-management. If necessary, referral to specialised care can take place. Persons in the control group will receive the care as usual. The primary outcome measures are the extent of participation in society and quality of life of the patient one year after a cardiac arrest. Secondary outcome measures are the level of cognitive, emotional and cardiovascular impairment and daily functioning of the patient, as well as the strain for and quality of life of the caregiver. Participants and their caregivers will be followed for twelve months after the cardiac arrest.A process evaluation will be performed to gain insight into factors that might have contributed to the effectiveness of the intervention and to gather information about the feasibility of the programme. Furthermore, an economic evaluation will be carried out to determine the cost-effectiveness and cost-utility of the intervention. DISCUSSION: The results of this study will provide evidence on the effectiveness of this early intervention service, as well as the cost-effectiveness and its feasibility. TRIAL REGISTRATION: Current Controlled Trials [ISRCTN74835019].