Post Resuscitation Care

Dr.Joseph RajeshHOD

Dept of AnesthesiologyIndira Gandhi Medical College & RI

Puducherry

Got back

ROSC ?

Not only

Return of Spontaneous Circulation (ROSC)But

Return of Pre Arrest Status (ROPAS)

Brain injury

PCAS

To minimize To correct

To Detect &TreatTo Manage

Brain injury

PCAS

6 Hours

Immediate

Early

Recovery

Rehabilitation

ROSC

Intermediate

20 minutes

8 Hours

24 Hours

72 Hours

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• Follow

ABC

Immediate

Early

Recovery

Rehabilitation

ROSC

Intermediate

20 minutes

6 Hours

24 Hours

72 Hours

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Base line neurological evaluation

Multiple Tasks Immediate

Early

Recovery

Rehabilitation

ROSC

Intermediate

20 minutes

8 Hours

24 Hours

72 Hours

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VentilatorySupport

Supportive care

EtiologySearch

Interventions

Investigationsoptmizing

Hemo dynamics

Optimization of Cardio Vascular functionEndOrgan perfusion

Oxygen

delivery

Perfusion pressure

CV system Optimization ( MAP >65 mmHg)

– Convert IO lines– Intra Venous Fluids

• Fluid boluses if tolerated• Avoid

– Dextrose containing– Hypotonic fluids

• RL preferred ( 1-2 L)

– Vasoactive agents• Epinephrine• Dopamine• Nor Epinephrine

Immediate

Early

Recovery

Rehabilitation

ROSC

Intermediate

20 minutes

8 Hours

24 Hours

72 Hours

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MAP of 80-100 for optimal cerebral perfusion

VentilatorySupport

Pulmonary dysfunction

RespiratorySupport

Pulmonary edema Aspiration Atelectasis

ToUnloadRespiratory demand

Strategies

Hypoxia

Hyperoxia

VentilatorySupport

• Goals:– SpO2 ~ 94-99 %– PaCO2 - 40 -45 mmHg.

• How?– Titrate FiO2– Set Tidal volume of 6-7 ml/kg – 10 -12 breath/mt

To ensure Oxygen delivery:

• Mixed/ central venous oxygen saturation– > 70 %– <70%

• Aggressive Resuscitation• Dobutamine

• Sr.Lactate– Serial vlaues– 10% clearence

EtiologySearch

Monitoring/Investigations

Interventions

Targeted Temperature management

Why ?

Hypothermia

• Who ?– comatose (usually defined as a lack of meaningful

response to verbal commands) after ROSC.• How long ?

– 12- 24 hours

How much ?

When ?

• 2 hours• Bernard SA, Treatment of comatose survivors of

out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–563.

• 8 hours• Neumar RW, et al. Circulation. 2008;118: 2452–

2483.

As Soon As Possible

How ?

External Internal

Complications

• Arrhythmias , hyperglycemia, Impaired coagulation– with an unintended drop

below target

• High infection rate

Monitoring

• Best:– esophageal, bladder (non

anuric patients) PA

• Inadequate:– Oral, axillary, Rectal

PRINCE Trial

• Pre Rosc Intra Nasal Cooling Effectiveness– Perflurocarbon into nasal cavity– Targeted cooling of cerebral structure

Interventions

• Coronary revascularization:– All patients with STEMI/New LBBB

• Coronary catheterization:– Ongoing hemodynamic instability

• Increasing biomarkers• Regional wall motion abnormalities

Coma is not a contraindication for PCI

• Glucose Control:– Hyperglycemia after arrest is detrimental

• Intensive therapy Hypoglycemnia

• Hypoglecemia Worse outcome

– Target Values 144 – 180 mg%

Interventions

Supportive care

• Sedation:– Opioids, anxiolytics, and sedative-hypnotic

• Various combinations

– Muscel relaxants• Only in life threatening agitation• Along with sedation

– Less duration– Frequent NM Monitoring

Caution during hypothermia

• Seizure control– EEG as soon as possible

– All comatose patients

– Myoclonus:– Clonazepam

– General Seizures– Benzodiazepines– Barbiturates– Phenytoin– Propofol

Supportive care

Supportive care

• Dysrhythmias:– Standard medical therapies– No prophylaxis required

• Steroids:– relative adrenal insufficiency in the post– cardiac

arrest phase• Associated with higher rates of mortality

– Routine use : Uncertain

Supportive care

• Neuroprotective drugs– Drugs tried

• Thiopentone,Glucocorticoids, nimodipine, lidoflazine,benzodiazepines, magnesium, coenzyme Q10

– Present status• No benefit

• Future Agents:• Xenon• Erythropoietin• Hydrogen sluphide

Prognostication

• Essential component of post cardiac arrest care.

Immediate

Early

Recovery

Rehabilitation

ROSC

Intermediate

20 minutes

6 Hours

24 Hours

72 Hours

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Prognosticative markers

• Prerequisite:– No confounding factors (hypotension, seizures,

sedatives, or neuromuscular blockers)• Clinical:

– No pupillary light reflex & corneal reflex at 72 hours (More reliable)

– Vestibulo –occular reflex, GCS < 5 at 72 horus (less reliable)

Prognosticative markers(Poor outcome)

• EEG changes – generalized suppression to 20 µ V, – burst-suppression pattern associated with

generalized epileptic activity– diffuse periodic complexes on a flat background

• SSEP– Bilateral absence of the N20 cortical response to

median nerve stimulation

Prognosticative markers(Poor outcome)

• Neuroimaging:– MRI:

• Extensive cortical and subcortical lesions

– CT parameters • quantitative measure of gray matter:white matter

Hounsfield unit ratio

• Biomarkers:– Neuron-specific enolase [NSE], S100B, GFAP, CK-

BB)

Summary

References

• 1. Part 9: Post–Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care– Circulation. 2010;122:S768-S786,

• 2.UptoDate 2012

THANK YOU