Total recall—Is it ethical not to sedate people during successful resuscitation?

Abstract

We would like to draw attention on a remarkable case of awareness during a prolonged cardiopulmonary resuscitation, which might have far reaching consequences for future CPR algorithms. A 24-year-old female was admitted to the ICU with progression of congestive heart failure caused by parvovirus B19 myocarditis during the 22nd week of pregnancy. Soon after admission, she suffered a cardiac arrest and resuscitation efforts were started immediately. After almost 1 h of desperate resuscitation, different aspects were discussed by the attending senior physicians ranging from cessation of CPR to emergency extracorporeal membrane oxygenation (ECMO) treatment. Finally, after successful extracorporeal support, the patient survived and was discharged in a very good condition. Intriguingly, after the event, the patient was able to recall specific and detailed descriptions of conversations at the resuscitation scene. She reported exactly about the physician's considerations if and how to proceed CPR and her disability to intervene. Studies have indicated that approximately 10% of cardiac arrest survivors report cognitive processes, including the ability to recall specific details of their resuscitation.1Parnia S. Spearpoint K. Fenwick P.B. Near death experiences, cognitive function and psychological outcomes of surviving cardiac arrest.Resuscitation. 2007; 74: 215-221Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar To our best knowledge, there is so far no evidence of awareness during (prolonged) CPR. We can report that in different blood gas analyses during CPR, the PaO2 level was raising which correlates with higher prevalence of near death experiences in cardiac arrest survivors along with the young age of the patient.2Parnia S. Waller D.G. Yeates R. Fenwick P. A qualitative and quantitative study of the incidence, features and aetiology of near death experiences in cardiac arrest survivors.Resuscitation. 2001; 48: 149-156Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, 3Greyson B. Incidence and correlates of near-death experiences in a cardiac care unit.Gen Hosp Psychiatry. 2003; 25: 269-276Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar During the whole resuscitation, however, our patient did not receive any sedative drugs. Following awareness during general anesthesia, patients report hearing conversations and sustain anxiety, panic and helplessness, which correlate with a higher incidence of post-traumatic stress disorders.4Moerman N. Bonke B. Oosting J. Awareness and recall during general anesthesia. Facts and feelings.Anesthesiology. 1993; 79: 454-464Crossref PubMed Scopus (284) Google Scholar Using what is understood from awareness it may, thus, be possible to conclude that most probably, during cardiac arrest, different levels of consciousness exist, depending on the degree of cerebral depression that occurs as a consequence of reduced cerebral blood flow.5Parnia S. Fenwick P. Near death experiences in cardiac arrest: visions of a dying brain or visions of a new science of consciousness.Resuscitation. 2002; 52: 5-11Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Far reaching implications for further behavior might emerge from our observation, the fact of possible consciousness during prolonged CPR, like the mandatory integration of sedative drugs into future algorithms. Further clinical trials like the AWARE-Study started in 2008 are needed to understand the etiology and significance of recall in patients who undergo cardiac arrest and clinical death. There are no potential conflicts of interest for any author.