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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
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

Search 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.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Olausson A, et al. Jan 2015 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.
Parnia S. et al 7 September 2014 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
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
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
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
Olausson A, et al Jan 2017 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.
RS Lundsgaard June 2018 Denmark	69-year old male patient with CPR induced awareness	Case report	Pain management	Fentanyl	Case report.
			ROSC	No

Comment(s)

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.

Clinical 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)

References

1. Olausson et al 2014 Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review Resuscitation Resuscitation 86 (2015) 44–48
2. Parina S et al AWARE—AWAreness during REsuscitation—A prospective study Resuscitation Resuscitation 85 (2014) 1799–1805
3. Pound J, et al CPR Induced Consciousness During Out-of Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon Prehospital Emergency Care August 23, 2016.
4. Rice D CPR induced consciousness: It’s time for sedation protocols for this growing population Resuscitation Resuscitation 103 (2016) e15–e16
5. Grandi T, et al. Six Cases Of CPR-Induced Consciousness In Witnessed Cardiac Arrest Prehospital Emergency Care 1/2017
6. Olausson A, et al Consciousness induced during cardiopulmonary resuscitation: An observational study Resuscitation Accepted 21 January 2017, 113 (2017) 44–50
7. RS Lundsgaard Awareness during CPR on cardiac arrest due to aortic dissection. European Journal of Anaestesia ,online appendix june 2018 Online appendix, june 2018