Abstract
Dear Editor,
We have recently conducted a national survey on the management of patients’ post cardiac arrest. We conducted the survey between April and August 2014 using the web-based site (www.surveymonkey.com) and publicised through the ICS. Target participants were intensive care doctors of all grades throughout the UK. Unfortunately, the response rate was low with only 47 respondents in total (representing at least 20 different hospitals).
In spite of the low response rate, this survey did allow the identification of important variation in clinical practice in the management of these patients. This particularly is most noted in the area of targeted temperature management with an almost even split between those aiming for a target temperature of 32–34°C versus 36°C.
In our view, this reflects current practice across the UK following publication of the Targeted Temperature Management trial. 1 This likely reflects a time lag between the publication and acceptance of new evidence and its incorporation into national and international guidelines and reflects a period of uncertainty for clinicians who deal with this dilemma on a regular basis. Indeed not only do practices appear to vary between units, it is quite possible that there may be variation within units, with different clinicians making their own interpretation of the current evidence base.
The International Liasion Committee for Resuscitation issued an interim positional statement clarifying that, pending formal consensus, current guidelines that aim for a temperature of 33°C should remain in force while recognising that individual clinicians may now choose to aim for a target of 36°C. This we feel has contributed to the current confusion and variation in practice.
With regard to access to percutaneous coronary intervention (PCI) following cardiac arrest, one-quarter of respondents felt that their patients would not have this routinely undertaken after ST-elevation myocardial infarction. Undoubtedly, PCI in this setting is becoming standard practice across much of the UK, but there still appears to be variation in access to this service. Common reasons stated for not undertaking this include the need to transfer an unstable patient, and non-acceptance by the tertiary cardiology service.
One-third of respondents had identified a change in practice with regard to neurological prognostication, with the change largely being to wait for longer periods before prognosticating (minimum of 72 h post arrest). Clinicians seemed to be guided most frequently by the circumstances surrounding the cardiac arrest and the presence of myoclonic status epilepticus, when making prognostication decisions. Our survey suggests that clinicians may be incorporating the use of electroencephalography (EEG) into routine practice. There also appear to be enthusiasts who routinely use somatosensory evoked potentials in their assessments.
In view of the low response rate to this survey it is impossible to interpret the findings as being representative of the national picture, but it does raise questions about inconsistencies in practice and a further national survey with more robust methods of information gathering would be extremely interesting.
The main message that we can take from this survey is that ‘in a small sample population, practice varied and this may reflect broader practice in the UK’. Further clarity around the care of patients post cardiac arrest appears to be needed.