Management of cardiac arrest in the cardiac catheterisation laboratory: guidelines tailored to place and occasion

Abstract

Since first compiled in 45 BCE as the Hippocratic Corpus, medical practice guidelines have served to summarise scientific knowledge and inform clinical management. In 1992, the International Liaison Committee on Resuscitation (ILCOR—the acronym being a deliberate play on words by adding ‘ill’ to the Latin ‘cor’ for heart) was formed by the major world resuscitation councils to carry forward this challenge in emergency cardiovascular care. Comprised of recognised international experts in resuscitation, ILCOR has since been charged with conducting evidence reviews of resuscitation science. The quality of this evidence is rigorously evaluated in terms of its certainty, consistency, indirectness, risk of bias and confounding influences using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology when formulating recommendations, and represents the current standard for timely and now continuously updated resuscitationrelated treatment guidance. The published guidance from ILCOR is then taken by the individual resuscitation councils (such as the American Heart Association, the European Resuscitation Council and others) and adapted to their localities, creating formal regional guidelines. ‘The Joint British Societies’ guideline on management of cardiac arrest in the cardiac catheter laboratory’ presents an additional adaptation of existing resuscitation guidelines. In this instance, the guidelines are applied to a specific place for such events—the cardiac catheterisation laboratory, and are tailored to a specific occasion—a witnessed cardiac arrest in a closely monitored patient. The need to adapt guidelines to this setting is understandable. Both the acuity of patients needing cardiac procedures and the complexity of the interventions themselves can provoke spontaneous or iatrogenic events resulting in haemodynamic destabilisation and cardiac arrest in the laboratory. The circumstances surrounding a cardiac arrest in a catheterisation laboratory also create a unique occasion for intervention. That is, unlike outofhospital cardiac arrest or arrest in other hospital locations, a patient in the laboratory is typically already being monitored and procedurally prepped. In addition, the event is usually witnessed by skilled providers from its outset; reasons for the arrest’s occurrence are likely already apparent or suspected, and invasive tools readily available for its management. Taken together, adapting resuscitation to this environment is sensible and the participating British Societies, which spanned a wide spectrum of specialties, are to be commended for this endeavour. In recognising this exemplary effort, it is also important to appreciate both the value and limitation of these guidelines. What the British Societies’ guidelines do well is provide a paradigm for resuscitation that takes advantage of the immediate