Section 7: Resuscitation

Edited by
Dr Jerry Nolan

7.1 Resuscitation training for anaesthetists

7.2 Equipment checks
7.3 Process of in-hospital cardiac arrest –
response times
7.4 Outcome after in-hospital cardiac arrest
7.5 Appropriateness of cardiac arrest calls
7.6 Paediatric resuscitation procedures
7.7 Quality of in-hospital cardiopulmonary
resuscitation
7.8 Implementation of therapeutic hypothermia
after cardiac arrest

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7.1

Resuscitation training for

anaesthetists
Dr J Soar, Dr J Nolan

Why do this All anaesthetists should be able to:

audit? n recognise and treat the patient at risk of cardiac arrest
n recognise and call for help if cardiac arrest occurs
n start cardiopulmonary resuscitation CPR based on current guidelines and attempt
defibrillation if indicated.
Anaesthetists who are involved regularly in resuscitation require greater knowledge of
resuscitation and peri-arrest care. Consultant anaesthetists rarely attend cardiac arrest unless
they have a critical care role.1 Anaesthetic trainees are often on resuscitation teams.
Frequent retraining (theory and practice) is required to maintain cardiopulmonary resuscitation
(CPR) skills and knowledge; although the optimal interval for retraining has not been
established.2 Regular updates may be more important for those who are rarely involved in
resuscitation.
Resuscitation training standards need to be achieved as part of hospital assessments for clinical
negligence (e.g. CNST – Clinical Negligence Scheme for Trusts).

Best practice: Experts working under the guidance of the International Liaison Committee on Resuscitation
(ILCOR) have recently reviewed the science supporting training in resuscitation.2 Several
studies have documented decay in healthcare provider advanced life support (ALS) skills and
research evidence

knowledge after ALS training and retraining from as little as 6 weeks to 2 years. Refresher
or authoritative
courses based only on knowledge did not prevent the decay in psychomotor skills. Significant
opinion
decay of ALS skills among anaesthetists can be demonstrated 6 months after completion of a
European Resuscitation Council (ERC) ALS course.3
Standards for clinical practice and training in CPR were published in 2004 by the Royal College
of Anaesthetists, the Royal College of Physicians of London, the Intensive Care Society, and the
Resuscitation Council (UK).4 This document indicates that clinical staff should undergo regular
resuscitation training to a level appropriate for their expected clinical responsibilities and their
skills should be updated annually.4

Suggested % of anaesthetists who have attended an in-house resuscitation update in the last year.
indicators % of anaesthetists who are members of a resuscitation team who hold a valid ALS provider
certificate.

Proposed 100% anaesthetists should have attended an in-house resuscitation update in the last year.
standard or target 100% anaesthetists who are members of a resuscitation team should hold a valid ALS provider
for best practice certificate.

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Suggested data to For all anaesthetists

be collected Indicate whether member of resuscitation team.
Evidence of annual update (in-house training or a national course).
Indicate whether ever held ALS provider certificate.
Indicate whether in possession of valid ALS provider certificate.
Reasons for failure to attend annual resuscitation training.

Common reasons Insufficient training resources.

for failure to Insufficient time.
reach standards Resuscitation training not considered a priority or deemed unnecessary.
Other training courses considered more useful to everyday practice.

References 1 Saravanan P, Soar J. A survey of resuscitation training needs of senior anaesthetists. Resuscitation
2005;664:93–96.
2 International Liaison Committee on Resuscitation. Part 8: Interdisciplinary topics. 2005 International
consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with
treatment recommendations. Resuscitation 2005;667:305–314.
3 Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation
2006;668:101–108.
4 Gabbott D et al. Cardiopulmonary resuscitation standards for clinical practice and training. Royal
College of Anaesthetists, Royal College of Physicians of London, Intensive Care Society, Resuscitation Council
(UK) October 2004 (see: www.rcoa.ac.uk/docs/Cardio-Resus.pdf).

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7.2

Equipment checks
Ms N Poplett, Professor G B Smith

Why do this For advanced life support to be effective, the cardiac arrest equipment needs to be readily
available and in good working order. Equipment failure has been identified as the responsible
factor for delays in instituting cardiopulmonary resuscitation in 18% of arrest calls.1 The
audit?
National Patient Safety Agency (NPSA) reported 86 incidents involving missing or broken
equipment on cardiac arrest trolleys2 and a separate survey of such trolleys in 2002/2003 found
that the equipment available varied considerably from recommended standards.3 Defibrillators
do also occasionally fail, but many errors are caused by poor defibrillator care and
maintenance.4 Inadequate training and a failure of operators to perform daily checks lead to
poor familiarity with the equipment and a failure to identify component failure or damaged
devices.4

The Resuscitation Council (UK) has a recommended cardiac arrest equipment list for
cardiopulmonary resuscitation of both adults5 and children6 and makes recommendations for
Best practice:

other equipment-related issues in its 2004 standards document.7 Institutions should adopt
research evidence
common cardiac arrest equipment recommendations based on these standards and should
or authoritative
ensure that regular equipment checks are performed.8 In areas where cardiac arrests are
opinion
relatively uncommon, this system is likely to maintain standards, detect deficiencies or
malfunctions, and also provide excellent teaching and training opportunities.

Suggested % of clinical areas with a list of ‘essential’ equipment including spares.

indicators % of clinical areas with a written record of performed checks.
% of clinical areas with evidence of a mechanism for reporting deficiencies.
For each clinical area, the % of days that a check is documented which includes availability,
function and cleanliness. Disposable equipment must be in date. The resuscitation trolley
should be easily mobile.
% of known resuscitation episodes for which a post-use check is documented.
% of reported equipment malfunctions that are corrected or substituted immediately on
reporting.

Proposed The first three indicators should be true for 100% of clinical areas. High risk areas may elect to
standard or target undertake such checks at each nursing shift handover.
for best practice There should be a documented check on 100% days and after 100% resuscitation episodes.
100% malfunctions or deficiencies should be corrected or substituted immediately on reporting.

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Suggested data to Name of clinical area. Presence of list of ‘essential’ equipment.

be collected Record of daily check, which should include a check of function, cleanliness and expiry date
where appropriate.
Record of check after resuscitation event.
Record of daily check of the mobility of the resuscitation trolley.
Record of critical incident with evidence of investigation of problem and solution.

Common reasons Absence of list of ‘essential’ equipment. There may be a need for a standardised check-list,
for failure to which should appear on every resuscitation trolley.
reach standards Failure of clinical area to identify responsible staff to perform checks.
Absence of a process to record and investigate critical incidents, some of which may be related
to equipment malfunction.

References 1 King D et al. Survey of cardiac arrests and cardiac arrest trolleys in a district general hospital. Br J Clin
Prac 1994;448:248–250.
2 National Patient Safety Agency. Patient Safety Bulletin 1. Rapid learning from reported incidents.
NPSA, London July 2005.
3 Hogh l et al. Variations in the provision of resuscitation equipment: survey of acute hospitals. Postgrad
Med J 2005;881:409–410.
4 Cummins RO, Chesemore K, White RD. Defibrillator failure. Causes of problems and
recommendations for improvement. J Am Med Assoc 1991;2264:1019–1025.
5 Resuscitation Council (UK). Recommended minimum equipment for in-hospital adult resuscitation.
RCUK, London October 2004 (see: www.resus.org.uk/pages/eqipIHAR.htm).
6 Resuscitation Council (UK). Suggested equipment for the management of paediatric cardiopulmonary
arrest (0–16 years) (excluding resuscitation at birth). RCUK, London 2004 (see:
www.resus.org.uk/pages/PCAequip.htm).
7 Gabbott D et al. Cardiopulmonary resuscitation standards for clinical practice and training. Royal
College of Anaesthetists, Royal College of Physicians of London, Intensive Care Society, Resuscitation Council
(UK) October 2004 (see: www.rcoa.ac.uk/docs/Cardio-Resus.pdf).
8 Dyson E, Smith GB. Common faults in resuscitation equipment – guidelines for checking equipment
and drugs used in adult cardiopulmonary resuscitation. Resuscitation 2002;555:137–149.

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7.3

Process of in-hospital cardiac

arrest – response times
Dr T Craft

Why do this Outcome following cardiac arrest and cardiopulmonary resuscitation (CPR) is dependent on
the timely administration of critical interventions such as early defibrillation and effective chest
compressions. The true effectiveness of in-hospital resuscitation is not known and its
audit?
assessment is hindered by the use of non-uniform nomenclature, different patient inclusion
criteria, and different data intervals. These differences prevent valid interhospital and
intrahospital comparisons. Examination of the resuscitation process against internationally
agreed data sets is essential for research into specific interventions and outcomes. Survival
rates will be improved by minimising the delay in starting resuscitation and attempting to
defibrillate ventricular fibrillation (VF) and ventricular tachycardia (VT) promptly.

Best practice: The European Resuscitation Council Guidelines for Resuscitation1 and the 2005 International
Liaison Committee on Resuscitation (ILCOR) consensus guidelines2 are the accepted best
practice for the resuscitation of adult patients. The Utstein template for the collection of
research evidence

resuscitation data has been updated recently.3 A prospective Swedish study reported an overall
or authoritative
survival of 33% when CPR was started in < 1 min compared to 14% when started > 1 min
opinion
after collapse (OR 3.06, CI 1.59–6.31).4 In patients whose rhythm was VF, 66% were discharged
alive if defibrillated ≤ 3 min compared with 20% when defibrillated ≥ 12 min.5

Suggested For all cardiac arrest patients:

indicators n % in whom the time of collapse to CPR < 1 min
n % whose initial arrest rhythm was VF/VT
n % defibrillated < 3 min after collapse.

Proposed For all cardiac arrest patients:

standard or target n 100% should be given CPR < 1 min
n 100% in VF/VT, defibrillation should be attempted < 3 min
for best practice
n 100% should have data collected in the Utstein format.

Suggested data to Total number of cardiac arrests where resuscitation is attempted.

be collected Time of witnessed/monitored cardiac arrest.
Time of first CPR attempt.
Time of first defibrillation attempt (if initial rhythm VF/VT).

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Common reasons Delays in initiating CPR.

for failure to Ward staff not trained and/or permitted to use a defibrillator.
reach standards Equipment not readily available.
Inadequate processes for recording data and populating local cardiac arrest registry.

Related audits 7.4 – Outcome after in-hospital cardiac arrest

7.7 – Quality of in-hospital cardiopulmonary resuscitation

References 1 Nolan JP et al. European Resuscitation Council guidelines for resuscitation 2005. Section 4: Adult
advanced life support. Resuscitation 2005;667 (Suppl 1):S39–85.
2 International Liaison Committee On Resuscitation. Part 4: Advanced Life Support. 2005 International
consensus on cardiopulmonary resuscitation and Eemergency cardiovascular care science with
treatment recommendations. Resuscitation 2005;667:213–247.
3 Jacobs I et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and
simplification of the Utstein templates for resuscitation registries. Resuscitation 2004;663:233–249.
4 Herlitz J et al. Characteristics and outcome among patients suffering from in-hospital cardiac arrest in
relation to the interval between collapse and start of CPR. Resuscitation 2002;553:21–27.
5 Herlitz J et al. Very high survival among patients defibrillated at an early stage after in-hospital
ventricular fibrillation on wards with and without monitoring facilities. Resuscitation 2005;666:159–166.

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7.4

Outcome after in-hospital

cardiac arrest
Dr C Gwinnutt
Why do this The principles of resuscitation after cardiac arrest are widely accepted.1 Despite improvements
in the science of resuscitation overall success rates after in-hospital cardiac arrest remain poor,
with only 15–20% of patients surviving to discharge. However, much better survival rates can be
audit?
achieved when there is minimal delay starting resuscitation, the initial arrest rhythm is ventricular
fibrillation or ventricular tachycardia (VF/VT) and defibrillation occurs rapidly (see audit 7.3). The
outcome of all cardiac arrest patients should be audited to enable meaningful targets for
improvement, quality assurance, and comparisons between institutions. This will be achieved only
if standardised criteria for reporting the process and outcome of resuscitation are used.

Best practice: In UK hospitals, Gwinnutt reported 61.7% immediate survival and 42.2% survival to discharge
after VF or VT, but only 17.6% overall survival to discharge after cardiac arrest.2 Uniformity in
definitions and reporting of results is essential to enable evaluation of structure, process and
research evidence

outcome of care. Data should be collected in the Utstein format.3

or authoritative
opinion

Suggested For all cardiac arrest patients:

indicators n % patients whose initial arrest rhythm was VF/VT
n % patients who have any return of spontaneous circulation (ROSC: defined as a palpable
pulse)
n % patients who survive the event
n % patients who survive to discharge from hospital
n neurological status of those surviving to discharge.

Proposed For all cardiac arrest patients:

standard or target n > 50% of patients whose initial rhythm was VF/VT should survive to discharge
n > 25% patients overall should survive to discharge from hospital
for best practice
n > 90% of survivors should be capable of independent living (i.e. Cerebral Performance
Category (CPC) 1 or 2)
n 100% cardiac arrests should have data collected in the Utstein format.

Suggested data to Data defined by Utstein template.3

be collected Absence of signs of circulation and/or considered for resuscitation
Resuscitation not attempted
n Do Not Attempt Resuscitation (DNAR) order in place
n Considered futile

Location of arrest
n Ward

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7.4

Emergency Department
n Operating room
n Critical Care Unit
n Other

Arrest witnessed/monitored
Aetiology
n Presumed cardiac
n Trauma
n Respiratory
n Unknown

Resuscitation attempted
n Any defibrillation attempt
n Any chest compression
n Any assisted ventilation
n First monitored rhythm
n Shockable (VT/VF)
n Non-shockable (asystole, pulseless electrical activity (PEA))

Outcome
n Any ROSC
n Survived event
n Discharged alive
n Neurological state at discharge (CPC score)

Common reasons Delays in initiating basic and advanced life support (see audit 7.3).
for failure to Lack of resuscitation officers, training facilities, regular training and updates for staff.
reach standards Lack of beds in appropriate areas (HDU, ICU or Coronary Care Unit).
Data not collected in Utstein format.

Related audits 7.3 – Process of in-hospital cardiac arrest – response times

7.7 – Quality of in-hospital cardiopulmonary resuscitation

References 1 International Liaison Committee On Resuscitation. Part 4: Advanced Life Support. 2005 International
consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with
treatment recommendations. Resuscitation 2005;667:213–247.
2 Gwinnutt CL, Columb M, Harris R. Outcome after cardiac arrest in UK hospitals: effect of the 1997
guidelines. Resuscitation 2000;447:125–135.
3 Jacobs I et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and
simplification of the Utstein templates for resuscitation registries. Resuscitation 2004;663:233–249.

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7.5

Appropriateness of cardiac
arrest calls
Dr P J F Baskett

Why do this To assist with the introduction of a scheme that enables patients to be identified for whom
audit? resuscitation would be inappropriate.

Best practice: Inappropriate attempts at resuscitation may produce unnecessary prolongation of an

unacceptable quality of life. Resuscitation attempts which contravene the patient’s expressed
wishes may constitute an assault. Resuscitation attempts which are clearly futile are a waste of
research evidence

resources and depress staff morale.1–4

or authoritative
opinion

Suggested Existence of a written do not attempt resuscitation (DNAR) policy for the hospital.
indicators % of ward based junior staff who have read it.
% of decisions made according to the policy or to the guidelines below.
% of cardiac arrest calls made for unsuitable patients. Unsuitability is clarified below.
% of those in whom resuscitation is attempted compared to the total of those who die in
hospital.

Proposed There should be a written DNAR policy.

standard or target 100% ward based junior staff should have read it.
100% decisions that a patient is not for resuscitation should be made:
for best practice

n by a senior doctor (consultant in charge)

n after consultation with junior staff
n after consultation with nursing staff
n having considered the opinion of the patient and/or the relatives.

No cardiac arrest calls should be made for unsuitable patients e.g:

n patients with a DNAR order in the notes
n inappropriate or futile resuscitation in the opinion of the auditor
n inappropriate or futile resuscitation in the opinion of the medical and/or ward staff.

Suggested data to Presence/absence of a written DNAR policy.

be collected Interview of ward based junior and senior staff to establish if they have read it.
Review of DNAR decisions made during the audit period on wards that have been chosen for
the audit, by looking at the notes and discussing with medical and ward staff.
Analysis of cardiac arrest calls during the audit period to assess unsuitability.
Total number of deaths in the hospital during the audit period.

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Common reasons Failure to agree a hospital policy or staff to be aware of it.

for failure to Failure of senior doctor to make and record decision.
reach standards Failure of senior doctor to appreciate futility of resuscitation efforts.
Variation in personal values and ethical attitude of the senior doctor.

References 1 Mohr M, Kettler D. Ethical aspects of resuscitation. Br J Anaesth 1997;779:253–259.

2 Baskett PJF. The ethics of resuscitation. In: Colquhoun MC, Handley AJ, Evans TR (Eds).
The ABC of resuscitation (5th edn). BMJ Publishing Group, London 2004: pp 102–106.
3 Cummins RO et al. Recommended guidelines for reviewing, reporting and conducting research on in-
hospital resuscitation; the in-hospital ‘Utstein style’. Resuscitation 1997;334:151–183.
4 Baskett PJF, Steen PA, Bossaert L. European Resuscitation Council. Guidelines for resuscitation 2005.
Section 8:The ethics of resuscitation and end-of-life decisions. Resuscitation 2005;667 Suppl
1:S171–S180.

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7.6

Paediatric resuscitation
procedures
Dr R Bingham
Why do this The British Paediatric Association has recommended that acutely ill children are treated in
specialist paediatric intensive care units.1 Sick children, however, will present initially to local
units, where staff may not have regular experience of acute paediatrics. All hospitals into which
audit?
a sick child may be admitted should be properly equipped and have staff trained to recognise a
problem early in order to institute treatment designed to stabilise the child prior to transfer to
the specialist unit.

Best practice: There is evidence that knowledge of even basic resuscitation has been inadequate in those who
may be called upon to deal with an acutely ill child.2,3 Following the introduction of specific
paediatric resuscitation training in the UK however, there has been both an improvement in
research evidence

knowledge and a reduction in mortality for children suffering from trauma.4,5 It is essential that
or authoritative
healthcare providers should have appropriate training for the treatment of the patients in their
opinion
care.

Suggested For clinical areas where children are treated (emergency department, theatres and children’s
indicators wards):
n % areas with specialised paediatric resuscitation trolley
n % days in audit period with a record of paediatric resuscitation equipment check, including
availability, function, cleanliness and expiry date where applicable
n % staff qualified in paediatric basic life support (BLS)
n % staff in resuscitation team with paediatric advanced life support (ALS) training.

Proposed For clinical areas treating children (emergency department, theatres and children’s wards):
standard or target n 100% should have specialist paediatric resuscitation equipment
n 100% days should have an adequate record of equipment check
for best practice
n 100% clinical staff should have paediatric BLS training
n 100% resuscitation team members should also have paediatric ALS training.

Suggested data to For each area treating children:

be collected n presence of trolley, presence and completeness of daily record, adequacy of checks
performed
n record of staff who have received paediatric ALS training.

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Common reasons Paediatric trolley not thought necessary.

for failure to Inadequate checking of equipment.
reach standards Inadequate provision of training and study time to attend courses.
Importance of specific paediatric training not appreciated.

References 1 The care of the critically ill child. Report of the multidisciplinary working party on paediatric intensive
care convened by the British Paediatric Association. British Paediatric Association, London 1993.
2 Oakley PA. Inaccuracy and delay in decision making in paediatric resuscitation, and a proposed
reference chart to reduce error. Br Med J 1988;2297:817–819.
3 Buss PW et al. A survey of basic resuscitation knowledge among resident paediatricians. Arch Dis
Childhood 1993;668:75–78.
4 Carapiet D et al. Changes in paediatric resuscitation knowledge amongst doctors. Arch Dis Childhood,
2001;884:412–414.
5 Roberts I et al. Reducing accident death rates in children and young adults: the contribution of
hospital care. Br Med J 1996;3313:1239–1241.

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Quality of in-hospital
cardiopulmonary resuscitation
Dr J Nolan

Why do this There is evidence that the quality of cardiopulmonary resuscitation (CPR) undertaken in and
out of hospital is suboptimal.1–4 Specifically, prolonged interruptions in chest compressions,
excessive ventilation rates and inadequate chest compression rates are common. The quality of
audit?
CPR is one of several factors that determines outcome after cardiac arrest. Poor quality CPR
can be addressed by improving training for healthcare providers. In turn, the efficacy of training
can be determined only by auditing how it is implemented in clinical practice.

Best practice: The International Liaison Committee on Resuscitation (ILCOR) has led a recent, extensive
review of the science supporting resuscitation practice.5 The European Resuscitation Council
(ERC) has published clinical evidence-based guidelines based on this review of the science.6 Both
research evidence

of these documents emphasise the importance of quality of CPR in determining outcome after
or authoritative
cardiac arrest. The chest compression rate should be 100 min-1, with the aim of delivering 80
opinion
compressions in each minute; short-term survival rates reduce with mean compression rates <
90 min-1.2 Excessive ventilation rates are common during CPR and reduce coronary perfusion
pressure.1,4 The ERC guidelines indicate that, once the airway is secured, the ventilation rate
during CPR should be 10 breaths min-1. When resuscitating a patient in ventricular fibrillation or
ventricular tachycardia (VF/VT), the delay between stopping chest compressions and delivery of
the shock correlates with short-term outcome – the quality of the VF starts to deteriorate after
just 10–20 s. The Resuscitation Council (UK) guidelines indicate that the pause between
stopping compressions and shock delivery should be less than 10 s.7

Suggested Analysis of indicators of quality of CPR is best undertaken in 2-min periods corresponding to
indicators the 2005 advanced life support (ALS) algorithm:
n % of 2-min periods with mean compression rate of 90–110 min-1
n % of 2-min periods with ventilation rate 8–12 breaths min-1
n % of time with no chest compressions (without a spontaneous circulation)
n % of intervals > 10 s between stopping chest compressions and shock delivery in VF/VT

Proposed For all cardiac arrests audited:

standard or target n 100% of 2-min periods with mean compression rate of 90–110 min-1
n 100% of 2-min periods with ventilation rate 8–12 breaths min-1
for best practice
n 0% time with no chest compressions (excluding periods with spontaneous circulation, and
time to check rhythm and pulse and deliver shocks)
n 0% of intervals > 10 s between stopping chest compressions and shock delivery in VF/VT.

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Suggested data to Some modified defibrillator/monitors will enable most of these data to be recorded
automatically,1,3 but most hospitals will not have this equipment. Manual data collection will
require the auditor to observe all resuscitation attempts to be included in the audit. Data for
be collected
collection include:
n compression rates for each 2-min period
n ventilation rates once the airway has been secured
n time with zero compressions
n intervals between stopping chest compressions and delivering shocks.

Common reasons Poor training, lack of understanding about the importance of uninterrupted chest compressions
and the harm caused by excessive ventilation, obsessively prolonged ‘safety’ checks before
defibrillation.
for failure to
reach standards

Related audits 7.3 – Process of in-hospital cardiac arrest – response times

7.4 – Outcome after in-hospital cardiac arrest

References 1 Abella BS et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.
J Am Med Assoc 2005;2293:305–310.
2 Abella BS et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal: a
prospective study during in-hospital cardiac arrest. Circulation 2005;1111:428–434.
3 Wik L et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.
J Am Med Assoc 2005;2293:299–304.
4 Aufderheide TP et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation.
Circulation 2004;1109:1960–1965.
5 International Liaison Committee on Resuscitation. 2005 International consensus on cardiopulmonary
resuscitation and emergency cardiovascular care science with treatment recommendations.
Resuscitation 2005;667:157–341.
6 Nolan JP, Baskett PJF. European Resuscitation Council guidelines for resuscitation 2005. Elsevier,
Amsterdam 2005.
7 Nolan J et al. Advanced life support (5th edn). Resuscitation Council (UK), London 2006.

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7.8

Implementation of therapeutic
hypothermia after cardiac arrest
Dr J Nolan
Why do this Two randomised clinical trials showed improved outcome in adults remaining comatose after
initial resuscitation from out-of-hospital ventricular fibrillation (VF) cardiac arrest, who were
cooled within minutes to hours after return of spontaneous circulation (ROSC).1,2 The study
audit?
patients were cooled to 32–34ºC for 12–24 h. Despite an advisory statement from the
International Liaison Committee on Resuscitation (ILCOR) advocating the use of mild
hypothermia in comatose survivors of out-of-hospital VF cardiac arrest, implementation of this
therapy in the UK has been slow.3

Best practice: The ILCOR Advisory Statement4 and European Resuscitation Council guidelines5 state:
unconscious adult patients with spontaneous circulation after out-of-hospital VF cardiac arrest
should be cooled to 32–34°C. Cooling should be started as soon as possible and continued
research evidence

for at least 12–24 h.6 Induced hypothermia might also benefit unconscious adult patients with
or authoritative
spontaneous circulation after out-of-hospital cardiac arrest from a non-shockable rhythm, or
opinion
cardiac arrest in hospital.
Excessive hypothermia increases the risk of complications.7
The patient should be rewarmed slowly (0.25-0.5°C h-1) and hyperthermia avoided. A period
of hyperthermia is common in the first 48 hours after cardiac arrest. The risk of a poor
neurological outcome increases for each degree of body temperature > 37°C.8

Suggested Retrospective chart review of all patients admitted to the intensive care unit (ICU) following
indicators out-of-hospital VF cardiac arrest. Record:
n % of comatose patients actively cooled excluding those with established exclusion criteria
(sepsis, coagulopathy, haemodynamic instability)
n % patients with start of cooling within 1 h of ROSC
n % patients achieving target temperature within 4 h
n % patients maintained in target range (32–34°C) for at least 12 h
n % patients with recorded temperature < 31°C
n % patients rewarmed slowly at 0.25–0.5°C h-1
n % patients with recorded temperature > 38°C within first 48 h after ROSC.

Proposed For all out-of-hospital VF cardiac arrest patients admitted to ICU without exclusion criteria for
standard or target therapeutic hypothermia:
for best practice n 100% patients actively cooled
n 100% patients have cooling started within 1 h of ROSC
n 100% patients achieve target temperature (34°C) within 4 h
n 100% patients are maintained in target range (32–34°C) for at least 12 h
n 100% patients are rewarmed slowly at 0.25–0.5°C h-1
n 0% patients with recorded temperature < 31°C
n 0% patients with recorded temperature > 38°C within first 48 h after ROSC.

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Suggested data to Total number of patients admitted comatose to ICU after out-of-hospital VF cardiac arrest.
be collected Number actively cooled.
Time of ROSC.
Time cooling started.
Patient temperature for at least the first 48 h.
Time taken to achieve target temperature.
Duration of active cooling.
Rate of rewarming.

Common reasons Unaware of the evidence for therapeutic hypothermia.

for failure to No protocol in place.
reach standards Emergency physicians and critical care staff not trained in the technique.
Misperception that this therapy increases ICU length of stay and incurs high costs.

References 1 Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the
neurologic outcome after cardiac arrest. N Engl J Med 2002;3346:549–556.
2 Bernard SA et al.Treatment of comatose survivors of out-of-hospital cardiac arrest with induced
hypothermia. N Engl J Med 2002;3346:557–563.
3 Laver SR et al. Therapeutic hypothermia after cardiac arrest. A survey of practice in intensive care
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