Interventions

Backrest elevation

By randomization, the patients will be allocated to have their headrest positioned at 5 degrees backrest vs 35 degrees straight elevation of backrest in Semi-Fowler’s position (elevated lower limp position) during the initial 72 hours or until extubated. The adherence to the assigned stratum will be checked every 8 hours and cuff pressure will be assessed and corrected if needed at the same time during the intervention period. The backrest position intervention may be temporarily canceled by the treating physician if needed for procedures or mobilization but will return to the assigned position if invasive ventilator treatment with orotracheal intubation is continued. The intervention will be terminated if the patient is extubated, or a tracheostomy is performed, during the intervention period of 72 hours.

Early vs. late wake-up call

By randomization, the patients will be allocated 1:1 to early wakeup call and potential extubation after ≤6 hours or late wakeup call and extubation between 28-36 hours after admission to the ICU. Definition for “ready for extubation” will be: GCS≥12, RASS 0- -1, able to raise arm or voluntary hand shake on command, spontaneous breathing trial and low ventilator settings (pressure support≤14, PEEP≤8 (10 if obese), and FiO2≤40%). A wakeup call may for both groups be aborted for the following reasons: seizures, respiratory distress, shock, or “other cause” with specification. Sedation prior to the scheduled wakeup calls is permitted in the early wakeup call group as needed for clinical care, while it is mandatory for the late wakeup call group. For both groups sedation as needed for clinical care will be permitted after the scheduled wakeup calls.

Dexamethasone vs placebo

High dose steroids to dampen systemic inflammation in resuscitated OHCA patients

By randomization, the patients will be allocated 1:1 to either dexamethasone (administered as dexamethasonephosphate) or placebo for three days. As soon as possible after admittance 20 mg of dexamethasonephosphate (Dexavit, Vital Pharma Nordic ApS, Denmark) or placebo will be given intravenously (i.v.) over 15 minutes – followed by 20 mg dexamethasonephosphate (or placebo) i.v. administered daily at 0600 (or at least 8 hours after initial dose) for two days, for a total of 3 doses.

Olanzapine vs placebo

Prophylactic use of olanzapine to prevent delirium in patients resuscitated from OHCA.

By randomization, the patients will be allocated 1:1 to olanzapine 10 mg (Olanzapin, Accord Healthcare B.V., The Netherlands) administered by feeding tube (or orally in awake patients) or matching placebo at admission and again the following two evenings until discharge from ICU or a maximum of 3 doses.

As soon as possible after arriving at the ICU: olanzapine/matching placebo is given in feeding tube. Thereafter 10 mg olanzapine or matching placebo will be given by feeding tube (or orally in awake patients) the following two evenings at 1800 (with a minimum of 12 hours between the initial doses) for a total of 3 doses. Due to the potential QT-prolonging effect, and accompanying concern for arrythmia, patients will be excluded prior to randomization if Long QT Syndrome (LQTS) has been confirmed or suspected, and all patients will be monitored by mandatory telemetry of heart rhythm for 72 hours or until life sustaining therapies are withdrawn. In case of delirium patients are treated according to standard care most often including dexmedetomidine, haloperidol or midazolam.