How to look after yourself and your patients after CPR
Today we’re talking all about how to look after yourself, and your patients, after cardiopulmonary resuscitation. CPR is high-pressured and, unfortunately, often is not successful; when it is successful, critical nursing care follows. Today I’m going to talk you through how to debrief with your team after an arrest, why it’s important to make time for you, and how to manage a patient following a return of spontaneous circulation.
Looking After Your Team
Debriefing
A debrief should take place as soon as possible after the arrest, with all members of the CPR team. This discussion should review the CPR effort, point out what went well, and identify any areas for improvement, both from a team and individual perspective.
It is really important to do this in a safe way. The goal of the debrief is not to blame anyone for any errors, issues or areas for improvement, but to identify these and create a plan to manage them. A safe, open and honest discussion is vital to the debriefing process.
The debrief is also an important opportunity to provide specific, positive feedback to individuals. Highlighting what went well is just as important as highlighting anything that could have been done better, and this should be prioritised.
In addition to the debrief, the team should use this opportunity to prepare for the next arrest. Any missing equipment from the crash box/trolley should be replaced, before its contents are checked, and the box is locked and labelled with the date and initials of the person who checked/stocked it.
As part of the debrief process, I like to confirm to the entire team if I am going to take responsibility for re-stocking the crash trolley, so that they know it is being done, and do not need to worry about this themselves.
Looking After You
Taking a Break
As well as debriefing, taking a break is important after CPR. There is a lot of adrenaline running around our bodies during/after CPR, and you’ll find yourself tiring afterwards.
This is also a prime opportunity for a patient safety challenge or error to occur - a physically tired and emotionally drained team member is much more likely to make a mistake (because we’re human!).
So take 5 and get yourself a cup of tea, or a minute of fresh air, whatever you need, at the earliest opportunity.
Self Care
In addition to taking a break at the time, make sure you’re looking after yourself generally. The veterinary gods often like to give us an arrest in the middle of a busy day, or with other critical patients to manage - busy days can put us at risk of burnout, and emotionally challenging situations like CPR on top of everything else can quickly leave us feeling ‘not quite ourselves’.
Make sure you’re prioritising things which make you feel good - whatever that looks like for you. Drink plenty of water, eat nutritious food, move your body and look after your soul.
Post-Arrest Patient Care
I’ve talked a lot over the last few weeks about what to do during CPR, but what about afterwards?
After a return of spontaneous circulation, patients need an enormous amount of monitoring and advanced nursing care.
The monitoring and treatment required can be broken down into 3 main categories:
Respiratory optimisation,
Haemodynamic optimisation, and
Neuroprotection
In addition to general critical nursing care.
Respiratory Optimisation
Respiratory monitoring is an important part of post-arrest care. Firstly, we need to determine if the patient is breathing spontaneously. If not, they will need to continue intermittent positive-pressure ventilation (IPPV).
We also need to monitor SPO2 and end-tidal carbon dioxide levels, and administer supplementary oxygen as required. The goal is a patient with an SPO2 of 94-98%, with an end-tidal CO2 of 32-43mmHg (in dogs) or 26-36mmHg (in cats).
Haemodynamic Optimisation
Close monitoring of perfusion parameters such as heart rate, pulse quality, mucous membrane colour, capillary refill time and arterial blood pressure are required during post-arrest care.
A systolic arterial pressure of 100-200mmHg, or mean arterial pressure of 80-120mmHg is the aim. If the patient is hypertensive, potential causes should be investigated and treated - for example, analgesia should be given to a painful patient (chest compressions hurt!)
A hypotensive patient should be assessed for evidence of hypovolaemia, vasodilation or poor cardiac contractility. Medications such as vasopressors (which constrict blood vessels to improve blood pressure) or inotropes (which improve the heart’s ability to contract) may be required.
Assessment of regular blood gases, lactate levels and packed cell volume is often required in the post-arrest patient. Elevated lactate levels can indicate poor perfusion, and in anaemic patients, blood product transfusion may be required.
Neuroprotection
Neurological abnormalities are common in post-cardiac arrest patients, due to poor blood (and therefore oxygen) delivery to the brain following cardiac arrest. Regular mentation assessments should be performed, and these patients should be closely monitored for any seizure activity.
Medications such as antiepileptic drugs, mannitol or hypertonic saline should be administered as required, under the direction of the veterinary surgeon.
In human arrest patients, there is evidence to suggest that a degree of hypothermia may be neuroprotective. Though this has not been investigated in cats and dogs, there is evidence to show that patient warming should be performed gradually. Reasonable warming rates are 0.25-0.5 degrees Celcius per hour; rates above 1-degree Celsius should be avoided.
General Nursing Care
In addition to the points discussed above, there are many other areas of consideration for us as nurses, when caring for these intensive patients. General nursing care of the critical patient is vast, and includes:
Monitoring of vital parameters, perfusion and hydration status, and neurological status
Airway management
Pain assessment
Management of eliminations
Management of nutrition and hydration
Recumbent patient care
Oral and ocular care
Physiotherapy
Bathing and grooming
Providing appropriate bedding
And much more!
Lastly, there is a high risk of subsequent arrest in a post-CPR patient. Around 35-45% of patients develop ROSC during CPR; however, only around 2-10% of those survive to discharge from the hospital. An important part of post-arrest care is knowing what the client wishes to do if the patient re-arrests (are they a DNR?), and being prepared for any further CPR attempts.
So, there is a lot to consider after a patient arrests! Nursing care of the post-cardiac arrest patient is challenging but incredibly rewarding. We also need to make sure we are looking after ourselves and our teammates, taking regular breaks to ensure we’re on top form for our patients, and being kind to ourselves when veterinary life is extra challenging.
What do you do to take care of yourself when veterinary life gets hard? Let me know below!
References
Fletcher, D. et al. 2012. RECOVER evidence and knowledge gap analysis on veterinary CPR part 7: Clinical guidelines. Journal of Veterinary Emergency and Critical Care, 22 (S1), S102-S131.
Yagi, K. 2017. Critical Components to Successful CPR. Today’s Veterinary Nurse, available from: https://todaysveterinarynurse.com/articles/critical-components-to-successful-cpr-the-recover-guidelines-preparedness-and-team/
