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POST RESUSCITATION CARE

Despite science-based guidelines for cardiopulmonary resuscitation (CPR), the survival rate after out-of-hospital and in-hospital cardiac arrest has not improved much over the last decade. The guidelines focus mainly on treatment until return of spontaneous circulation (ROSC). Peberdy and Ornato suggest that post resuscitation care could be the missing link in the Chain of Survival. They write: “It is ludicrous to commit tremendous fiscal and personnel resources to evaluating therapies for improving survival from the cardiac arrest event itself without acknowledging that the current state of post resuscitation care is widely variable and most often performed by clinicians unfamiliar with specific post resuscitation medical care.”

(Peberdy, M.A. & Ornato, J.P. Post-resuscitation care: Is it the missing link in the Chain of Survival? Resuscitation 2005;64:135-137)

Based on the assumption that in-hospital factors could relate to neurologically intact survival, several authors suggest that a standardized treatment protocol be followed for post resuscitation care. The post resuscitation phase is associated with a sepsis-like syndrome. Treatment of both the global ischemic brain damage and the dysfunctional heart during the reperfusion phase is the main challenge. The content of this section will be based on recommendations from the following sources:

 Initial Data Gathering (after ABC’s are stabilized)

  1. History: Review presence of advance directives and overall prognosis
  2. Baseline neurological evaluation to rule out other causes; document Glasgow Motor Score
  3. Initial lab studies:
    • ABG
    • CBC/platelets/PT/PTT
    • Chem 7, plus Ca/Mg/Phos
    • Lactate, CPK-MB, troponin
  4. Serial laboratories:
    • Glucose, K+, and lactate q. 6 hrs X 2 days
    • Repeat CPK-MB, troponin at 6 hrs
    • CBC/platelets/PT/PTT, Chem 7/BUN/Cr, Ca/Mg/Phos q. 12 hrs X4
  5. Chest x-ray; repeat in AM and after 72 hours to rule out aspiration pneumonia
  6. Head CT to rule out intracranial hemorrhage
  7. 12-lead ECG after initial stabilization and repeat q. 8 hrs X2 and prn to rule out acute coronary syndrome
  8. Cardiology consultation
  9. Echocardiogram to rule out regional wall motion abnormality and severe contractile dysfunction; consider repeat 24-48 hrs after ROSC 

Monitoring

1. Continuous ECG monitoring
2. Arterial line for continuous arterial blood pressure monitoring
3. Foley catheter for continuous temperature and urine output monitoring
4. Central venous catheter with CVP monitoring
5. Consider PA catheter if CVP > 15 mm Hg or Coronary Heart Failure or escalating vasopressors
6. Oxygen saturation continuous monitoring
7. ABGs
8. Continuous EEG monitoring beginning within 6-12 hours while paralyzed
9. Neuro checks q. 2 hrs while paralyzed
10. Twitch monitor while neuromuscular blockade

Therapeutic Hypothermia

The American Heart Association recommends that patients remaining comatose after ROSC following a witnessed ventricular fibrillation cardiac arrest should receive therapeutic hypothermia (TH) management. TH may also be beneficial for other primary rhythms. See the section in Resuscitation Central on Therapeutic Hypothermia. Begin TH as soon as possible, even in the emergency department, and cool the patient rapidly to 32-34°C for 12-24 hours. If TH is contraindicated, hyperthermia, which is common during the first 24 hours after cardiac arrest, must be avoided. 

Revascularization

Coronary thrombi are frequently found after sudden cardiac death, and most cardiac arrest patients have coronary artery disease. Thus, immediate coronary angiography is often performed among survivors of cardiac arrest. Successful percutaneous coronary intervention (PCI) has been shown to be a predictor of increased survival in the cardiac arrest victim. Thus PCI is indicated when cardiac arrest is thought to be caused by myocardial ischemia/infarction and a culprit lesion is found at coronary angiography.

(Spaulding, C.M. et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. NEJM 1997;336:1629-1633)

Thrombolysis is recommended for patients with ST elevation if there are no facilities for immediate PCI. Coronary artery bypass grafting is indicated for patients with left main stenosis or triple vessel coronary artery disease if the cardiac arrest was thought to be caused by ischemic heart disease. If no intervention is performed with angiography, the use of antiplatelets and anticoagulation should have a positive effect because of the coagulation disorder occurring after cardiac arrest. 

Hemodynamics

Titrate IV fluids to ensure volume repletion using CVP as a guide. A large amount of volume expansion is required due to the myocardial dysfunction. The goal for mean arterial pressure is 80-100 mm Hg, though European hospitals have often chosen > 65-70 mm Hg. For hypotension norepinephrine and dobutamine may be used. Dopamine and epinephrine may be added, as well as the intra-aortic balloon pump. Nitroglycerin is used when the patient is hypertensive. Consider furosemide if patient is in heart failure. Transfuse red blood cells if the hemoglobin is < 10 mg/dl. 

Blood Glucose

Hyperglycemia and hypoglycemia should be avoided. Non-intervention studies have shown increased mortality among patients following cardiac arrest with high levels of blood glucose during reperfusion. An intensive insulin protocol should be followed to keep the blood glucose value in the range of 80 to 110 mg/dl. 

Ventilation

Hyperventilation should be avoided, which might reduce cerebral perfusion. SpO2 should be maintained at 95-98, and pCO2 at 5-6 kPA. Long-term treatment with artificial ventilation should be limited to < 2-3 days if there is no cardiac, pulmonary or other complications.

Acid-Base Status, Electrolytes

Acidosis and hyperkalemia are adverse prognostic factors in the post resuscitation phase. So it seems reasonable to avoid severe acidosis, hyperkalemia, and hypokalemia. Hypomagnesemia is associated with adverse outcome in critically ill patients, however, there is no randomization trial evaluating magnesium in post resuscitation care. It seems reasonable to avoid hypomagnesemia.

Anti-arrhythmic Therapy

A meta-analysis of three trials comparing an implantable cardioverter defibrillator (ICD) to treatment with anti-arrhythmic medication (amiodarone, metoprolol) in patients following cardiac arrest showed a significant reduction in death from any cause with an ICD. Patients with a left ventricular ejection fraction < 35% derived significantly more benefit from ICD therapy than those with better left ventricular function.

(Connolly, S. J. et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study. European Heart Journal 2000;21:2071-2078)

Beta blockers are recommended for known or recent myocardial infarction and/or heart failure, and for cardiac arrest of presumed cardiac etiology. Due to the bradycardia associated with hypothermia, beta-blockers are not given during this period. Amiodarone can be used for recurring ventricular arrhythmias despite beta-blockade or if beta-blockade is not tolerated, though the balance of evidence favors use of an ICD.

Anticonvulsant Therapy

Seizures occur after cardiac arrest in up to 30%-40% of cases and are associated with a worse outcome. Early prevention and treatment of seizures is advocated although the scientific evidence for this strategy is weak. 

Other Usual ICU Care

It is recommended that antibiotics be initiated within one hour to prevent aspiration pneumonia. Treatment should be continued for three days, and then reassess the need based on the chest x-ray and/or presence of sepsis. Gastrointestinal and deep vein thrombosis prophylaxis should routinely be provided. 

Do Not Resuscitate Status

A large number of patients who initially survive a cardiac arrest are given a do not resuscitate (DNR) status early after ROSC without giving sufficient time to determine whether the patient will experience neurological recovery. Prognosis should not be predicted and care should not be withdrawn based on neurologic prognosis before 72 hours after ROSC. Hypothermia prolongs the effect of sedatives/analgesics so that clinical prognostication is even more difficult.

The Future

With the exception of hypothermia, which is an established post resuscitation therapy, the relationship between negative in-hospital prognostic factors following resuscitation and how treatment can affect outcome has not been investigated. Further interventional studies should focus on post resuscitation care, so that an evidence-based standard of care that improves survival can be established.