Posted by Circulation AHA Releases December 18, 2023 at 10:52 AM on Dec 18th 2023
AHA Releases Updated Guidance for Adult Advanced Cardiovascular Life Support in Science
AHA Releases Updated Guidance for Adult Advanced Cardiovascular Life Support in Science
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Today, the AHA issued a 2023 Focused Update on Adult Advanced Cardiovascular Life Support (ACLS) that was published in its flagship journal, Circulation. The updated guidance provides recommendations that complement or refine the 2020 AHA Guidelines for CPR and ECC.
A major point of this Focused Update redefines the concept of targeted temperature management to
temperature control, thereby including strategies of hypothermic temperature control, normothermic temperature control, and temperature control with fever prevention. There is also a new section on diversity, equity and inclusion.There will be no changes to ACLS courses and training materials at this time. In light of this new science, the AHA is providing a document for the ACLS Training Network titled, “2023 ACLS Focused Update: Implications for Training ACLS Providers,” which is available on Atlas. The document is also at the end of this blog post. For purposes of teaching ACLS courses, Instructors should be aware that these new guidelines may be followed, should a student choose to use these guidelines in practice and testing. As new training materials are developed, the AHA will continue to review how the recommendations can be implemented in training.
To help ACLS Instructors and healthcare providers understand more about the science
behind the recommendations, the AHA did a Q&A with Jon Rittenberger, MD, MS, who served as the writing group chair for the ACLS Focused Update. Dr. Rittenberger is the Chief Medical Officer at Guthrie Robert Packer Hospital. He also is a Professor of Emergency Medicine at Geisinger Commonwealth School of Medicine.
Q: What are the main changes in the 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support that you think it’s important for ACLS Instructors and healthcare providers to understand? A: Our understanding of cardiac arrest care is constantly evolving. Guideline updates are needed to ensure we bring the latest advances to the bedside when caring for an individual patient. In the 2023 Guideline Update, the writing group reviewed the literature in several key areas: Temperature management, Extracorporeal Mechanical Oxygenation (ECMO), coronary angiography, seizure management, and pharmacologic adjuncts during CPR. We also included two new sections: organ donation and diversity, equity and inclusion as these have not been addressed in the guidelines.
Q: Why did the writing group recommend the changes? A: Since the 2020 guidelines, there have been multiple studies in resuscitation science. For example, 4 randomized, controlled trials have been conducted evaluating emergent coronary angiography versus a delayed or selective strategy in post-arrest patients. None of these studies demonstrated a benefit to emergent coronary angiography. The writing group updated the guidelines to reflect these new data and balance the fact that emergent coronary angiography may help select patients (i.e. those with shock, electrical instability or signs of ongoing ischemia), but does not appear to benefit an undifferentiated cohort. Summarizing the findings of the literature and placing them in clinical context is critical for practicing clinicians.
Q: As it relates to hypothermia and targeted temperature management, what was the AHA’s previous scientific guidance?
A: Previously, the AHA recommended maintaining a constant temperature between 32°C and 36°C in the post-cardiac arrest phase. New data support expanding the temperature zone from 32°C-37.5°C. There is also a shift in terminology to temperature control rather than targeted temperature management.
Q: With the updated guidance in the ACLS Focused Update, how does this translate into clinical practice? A: These new guidelines can affect care in several ways. Using the example of an out-of-hospital cardiac arrest with ventricular fibrillation as the primary rhythm, we would not routinely use calcium during the acute resuscitation (unless there was a compelling reason such as AV fistula on exam that suggests hyperkalemia as a likely etiology). After ROSC, unless the 12 lead EKG demonstrated STEMI, there would likely not be a reason for emergent coronary catheterization. When a core temperature is obtained, simply maintaining the temperature between 32°C and 37.5°C is reasonable. A temperature management device is still needed, but there is less urgency to alter temperature to a specific number. These new guidelines give specific definitions of EEG findings on the ictal-interictal spectrum to illustrate what findings would be considered for treatment. Finally, there is guidance on organ donation considerations to help clinicians should the patient progress to brain death or is deemed eligible for donation after cardiac death.
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