Pain management in patients who show awareness during CPR
Date First Published:
August 19, 2018
Last Updated:
August 19, 2018
Report by:
Rune Sarauw Lundsgaard, MD; Resident in Anesthesiologi (Departement of Anesthesiology, Nykøbing Falster Sygehus, Denmark)
Search checked by:
Kristine Sarauw Lundsgaard, Departement of Anesthesiology, Nykøbing Falster Sygehus, Denmark
Three-Part Question:
In [patients who shows signs of awareness during CPR] are [pain management and/or sedation] indicated to [improve patients' outcome] while continuing CPR
Clinical Scenario:
As attending physisian in the cardiac arrest team your patient suddenly shows signs of awareness as CPR is performed even though spontaneus circulation is still not returning. Besides the ethical and communicative issues rising in your head, you wonder how you and the team should approach pain management and sedation while continuing cpr.
Search Strategy:
1.Cochrane Library accessed via http://www.thecochranelibrary.com/
2. MEDLINE was searched using pubmed interface
3. Google scholar was searched for (grey) litterature
2. MEDLINE was searched using pubmed interface
3. Google scholar was searched for (grey) litterature
Search Details:
1. Cochrane: [Awareness during CPR] secondly [CPR-induced awareness]
2. MEDLINE 1 (((((((Cardiopulmonary Resuscitation) OR Heart Arrest) OR CPR) OR Heart Massage) OR cardiac compression) AND Awareness) OR awareness during cpr) OR awareness during Cardiopulmonary Resuscitation Sort by: Best Match
MEDLINE 2. Search awareness during cpr Sort by: Best Match
Google Scholar: Awareness CPR case
2. MEDLINE 1 (((((((Cardiopulmonary Resuscitation) OR Heart Arrest) OR CPR) OR Heart Massage) OR cardiac compression) AND Awareness) OR awareness during cpr) OR awareness during Cardiopulmonary Resuscitation Sort by: Best Match
MEDLINE 2. Search awareness during cpr Sort by: Best Match
Google Scholar: Awareness CPR case
Outcome:
Cochrane: 6 found, 1 relevant paper
MEDLINE 1: 577 found, 3 selected, 3 relevant papers
MEDlINE 2: 284 found, 8 selected, no additional relevant papers
Google scholar: a total of 3 further case reports and 1 multi case report (2016-2018) was found.
MEDLINE 1: 577 found, 3 selected, 3 relevant papers
MEDlINE 2: 284 found, 8 selected, no additional relevant papers
Google scholar: a total of 3 further case reports and 1 multi case report (2016-2018) was found.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review Olausson et al 2014 Jan-15 Australia | Patients with return of consciousness during ongoing cardiopulmonary resuscitation | Systematic review | Papers regarding Awareness during CPR | 10 case reports | The data consists of case reports. Not possible to compare data about sedation or pain management due to many confounders: Different reasons for cardiac arrest; non-consistent use of mecanical compression; time of CPR ranging from 20 min to 280 min. |
| Sedation of patients | 4 out of 10 | ||||
| Types of sedation | 2 non-specifed, 1 Midazolam, 1 morphine. | ||||
| AWARE—AWAreness during REsuscitation—A prospective study Parina S et al 07-Sep-14 USA + UK | Cardiac arrest (CA) survivors | Prospective study of levels of awareness in Cardiac arrest (CA) survivors | Patients reports of different levels of awareness during CPR. | 9%. Consciousness may be present in patients despite clinically detectable signs of awareness | Only data from suvivors No data regarding pain management or sedation |
| CPR Induced Consciousness During Out-of Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon Pound J, et al August 23, 2016. Canada | 52-year-old male with awareness during CPR. | Case report | Survival | yes | Case report. |
| Sedation of patient | Midazolam (only available) | ||||
| Suggested sedation | Ketamine given its hemodynamic properties but has side effects | ||||
| CPR induced consciousness: It’s time for sedation protocols for this growing population Rice D 2016 USA | Patients with cardiac arrest showing signs of awareness: spontaneous eye opening, purposeful movement, verbal response to include moaning | Letter to the editor including Protocol for pain management | Protocol for pain management Nebraska | Suggests Ketamine bolus IV or IM, possible repeated after 5-10 minutes | There is still minimal scientific evidence to support protocols regarding pain management during CPR |
| Six Cases Of CPR-Induced Consciousness In Witnessed Cardiac Arrest Grandi T, et al. 2017 Italy | Six case reports | Intervention/sedation: | Either propofol or fentanyl was used | Case reports Many confounders: age 22-86 years old, different co-morbidities and different initial rythms. 4 sedated, but no protocol was used. Only ROSC and survival to discharge |
|
| Survival: | 3 out of 4 sedated patients survived, but no additional outcomes was reported | ||||
| Sedation | 4 out of 6 patients | ||||
| Consciousness induced during cardiopulmonary resuscitation: An observational study Olausson A, et al Jan-17 Australia | Adult out-ofhospital cardiac arrest patients treated by emergency medical services (EMS) were included. association between CPRIC and survival to hospital discharge |
Retrospective study of registry-based data from Victoria, Australia between January 2008 and December 2014. |
CRIC: Cardiopulmonary resuscitation-induced consciousness | 0,7 % CRIC (117 patients) | Although the study identified significantly higher rates of ROSC among patients with CPRIC compared to those without, there was no difference in the proportion of survivors being discharged home following OHCA. |
| CRIC and survival | CPRIC was independently associated with an increased odds of survival to hospital discharge in unwitnessed/bystander witnessed events | ||||
| Sedation | (37.5%) patients with CPRIC received treatment with one or more of midazolam (35.7%), opiates (5.4%) or muscle relaxants (3.6%) | ||||
| Sedation and survival | When stratified by use of these medications, CPRIC in unwitnessed/bystander witnessed patients was associated with improved odds of survival to hospital discharge if medications were not given (OR 3.92, 95% CI: 1.66, 9.28; p = 0.002), but did not influence survival if these medications were given (OR 0.97, 95% CI: 0.37, 2.57; p = 0.97). | ||||
| Choice of sedation | The administration of consciousness-altering medications suchas midazolam, opiates and muscle relaxants was not associated with survival benefits. These findings contributeto concerns that sedatives, such as benzodiazepines, could impair vasomotor tone leading to a reduction in coronary perfusion pressures. Points to Ketamine as drug of choice. | ||||
| Awareness during CPR on cardiac arrest due to aortic dissection. RS Lundsgaard Jun-18 Denmark | 69-year old male patient with CPR induced awareness | Case report | Pain management | Fentanyl | Case report. |
| ROSC | No |
Author Commentary:
Papers on Awareness during CPR consists mostly of case reports, however one recent prospective study adresses the topic.
Current Resuscitation Council recommendations do not include pain management or sedation guidelines
Protocoles on pain mangement when patients show awareness during CPR are increasingly publiced
Further studies to support the choice of drug (Ketamine?) is needed.
Current Resuscitation Council recommendations do not include pain management or sedation guidelines
Protocoles on pain mangement when patients show awareness during CPR are increasingly publiced
Further studies to support the choice of drug (Ketamine?) is needed.
Bottom Line:
Awarenes during CPR or CPR induced Consciousness (CPRIC) is rare but increasingly reported. The increase is associated with improved CPR and potentially related to use of mechanical devices (grade A)
CPRIC is potentially associated with a better outcome (grade C)
Sedatives such as Midazolam and morphine is not assosiated with improved outcome (grade C)
Ketamine is suggested as choice of drug due to its hemodynamic properties, but is has sideeffects (not sufficient scientific evidence for use in CPR)
CPRIC is potentially associated with a better outcome (grade C)
Sedatives such as Midazolam and morphine is not assosiated with improved outcome (grade C)
Ketamine is suggested as choice of drug due to its hemodynamic properties, but is has sideeffects (not sufficient scientific evidence for use in CPR)
References:
- Olausson et al 2014. Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review
- Parina S et al. AWARE—AWAreness during REsuscitation—A prospective study
- Pound J, et al. CPR Induced Consciousness During Out-of Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon
- Rice D. CPR induced consciousness: It’s time for sedation protocols for this growing population
- Grandi T, et al.. Six Cases Of CPR-Induced Consciousness In Witnessed Cardiac Arrest
- Olausson A, et al. Consciousness induced during cardiopulmonary resuscitation: An observational study
- RS Lundsgaard. Awareness during CPR on cardiac arrest due to aortic dissection.