Brain Resuscitation: Monitoring, Therapies, and Techniques for Neurocritical Care, Study notes of Medicine

Download Brain Resuscitation: Monitoring, Therapies, and Techniques for Neurocritical Care and more Study notes Medicine in PDF only on Docsity!

Brain Resuscitation

Neurocritical Care – Monitoring & Therapies CCCF November 2, 2016 Anne-Marie Guerguerian Critical Care Medicine, The Hospital for Sick Children University of Toronto

Disclosures

Pediatrician

• Financial: none
• Volunteer :

Heart and Stroke Foundation of Canada

Resuscitation Paediatric Task Force

International Liaison Committee on

Resuscitation Pediatric Task Force 2015

Terminology?

C-CPR or N-CPR or B-Resuscitation

Cerebral - CardioPulmonary Resuscitation?

Neuro - CardioPulmonary Resuscitation?

Brain Resuscitation?

Flow in cardiopulmonary arrest

(CPA), resuscitation and post

resuscitation care period

Low None Some, high and/or low Normal Normal Cerebral blood flow Time t^0 t1^ t2^ t CPA CPR ROSC or ROC

ILCOR, HSFC & AHA 2015

* Most if not all systematic reviews in PICO

format incorporated a functional neurological

outcome in their constructs

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9298365/k.7519/ 5_Canadian_Resuscitation_and_First_Aid_Guidelines.htm http://circ.ahajournals.org/content/132/16_suppl_1.toc

Learning objectives: recent literature

Monitoring Therapies Time to reperfusion   Oxygenation   Carbon dioxide   TTM Temperature Targeted Management

Brain Imaging - CT   (?) Electrophysiology - EEG   (?)

Importance of clock time

• Quality resuscitation measures
  • time-to-actions
• Decisions related to advanced

interventions

• Conventional CPR vs E-CPR
• Surrogate for severity of ischemia
• Decisions to change goals of care

GWTG Registry In Hospital

Cardiac Arrest in Children

80 children 54% survived ECMO 34% survived hospital discharge Cause of death ischemic brain injury JTCVS 2007

Benchmark < 30 min

How to reduce time to ROC?

A + B + C < 30 min

A: 0 min

B: < 10 min for C-CPR

C: < 20 min for E-CPR

CPA C-CPR E-CPR

A B C

ROC

Survival to hospital discharge & survival

with favorable neurological outcome in

CPA >= 10 min

E-CPR vs C-CPR:

Adjusted OR, 2.80; 95% CI 2.13-3.69; P<0. OR, 2.64; 95% CI 1.91-3.64; P<0. Propensity Matched OR, 1.70; 95% CI 1.33-2.18; P<0. OR, 1.78; 95% CI 1.31-2.41; P<0. Note median E-CPR 45 min vs 27 min Javier J. Lasa et al. Circulation. 2016;133:165- 176

Benchmark < 20 min?

How to reduce time to ROC?

A + B + C < 20 min

A: 0 min

B: < 0 min for C-CPR

C: < 20 min for E-CPR

CPA C-CPR E-CPR

A B C

ROC

POST RESUSCITATION CARE

Monitoring and Therapies

• TTM: Normothermia or Hypothermia
• Controlled re-oxygenation and CO 2

normalization

• Hemodynamic stability
• Seizure detection and control
• Overall supportive care