Cardiopulmonary Resuscitation In ICU

Introduction
Cardiopulmonary resuscitation (CPR) is a common therapy in the intensive care unit (ICU), and begins with standard advanced cardiac life support (ACLS) algorithms as published by American Heart Association guidelines, which were designed for application in non-ICU settings, often proceeding to more advanced therapies.
Definitions and Terms
• Respiratory arrest: Cessation of effective breathing due to a variety of causes including airway obstruction,drugs, central nervous system pathology, or intrinsic pulmonary disease
• Cardiac arrest: Cessation of effective circulation due to a variety of causes including arrhythmias, primary cardiac muscle failure, pericardial disease, thoracic pathology (ie, pneumo- or hemothorax), and circulatory incompetence (ie, hemorrhage, sepsis, anaphylaxis)
• Airway: The establishment of a patent airway
• Breathing: Encompasses both ventilation and oxygenation
• Circulation: Encompasses both cardiac and vascular function
Techniques
• The indications for CPR in an ICU are identical to those in any other setting, that is, loss of airway, breathing, and/or circulation.
• As with resuscitation in any patient, advanced directive should be evaluated prior to initiation of resuscitation to ascertain whether there are any limitations to such as “Do not intubate” or “No cardiopulmonary resuscitation.”
• In many cases, the need for intervention will be identified by an alarm from one of the bedside physiologic monitors unless cardiac or respiratory arrest is witnessed.
—Respiratory arrest—typically identified by pulse oximeter alarm, bradycardia, or respiratory rate alarm.
—Cardiac arrest or arrhythmia—identified by automated arrhythmia detection or blood pressure alarm.
• In the event of respiratory arrest, the patient should be assessed for the presence or absence of spontaneous respiratory efforts and airway patency.
—A patent airway should be established using maneuvers such as head and neck positioning, oral or nasal airways, and endotracheal intubation if appropriate.
—Ventilation should be established with a resuscitation bag and/or mechanical ventilator if appropriate.
• In the event of cardiac arrest, the patient should be assessed for the presence or absence of an effective electrical rhythm.
—In the event that there is a rhythm, the patient should be assessed for a pulse either by palpation, manometry, or arterial line tracing.
—If there is an effective rhythm, but no pulse, the typical causes for electromechanical dissociation should be assessed including tension pneumothorax, pericardial tamponade, and hypovolemia.
—In the event that an effective rhythm is absent, initial resuscitations should be directed toward the resumption of circulation using chest compressions (Figure 1-1), pacing, defibrillation (Figure 2-2), and/or cardioversion as warranted.
• Blood tests should be secured as soon as feasible to evaluate oxygenation; ventilation; acid-base status; serum hemoglobin; and electrolytes, including potassium, magnesium, and calcium.








Clinical Pearls and Pitfalls
• Unlike many regular patient floor rooms, ICU rooms are typically equipped with resuscitation bags, suction, oxygen delivery systems. The time between recognition of a cardiopulmonary arrest and intervention is usually brief, enhancing the likelihood of successful resuscitation.
• Certain standard ACLS interventions may be inappropriate in certain ICU populations:
—Chest compressions may be contraindicated after certain cardiac surgical procedures, that is, valve replacement, in which compressions may cause tearing of suture lines—in this case open cardiac massage is the preferred intervention.
—Direct laryngoscopy may be relatively contraindicated in certain patient populations, that is, laryngeal or tracheal surgery, where bronchoscopically directed airway management preferred.
• The effectiveness of chest compressions can be monitored on arterial line tracings when available.
• Excessive manual ventilation can cause auto-PEEP and insufficient venous return to the heart.
• Correct endotracheal tube position should be confirmed with carbon dioxide detection devices, although these devices may be inaccurate in full circulatory arrest and the absence of effective circulation.
• Potential pharmacologic causes, (ie, narcotics, potassium overdose, wrong, or runaway infusion) for cardiopulmonary arrest should be considered early in any ICU patient because of the higher than normal likelihood of exposure to pharmacologic interventions in this population.