post resuscitation syndrome - andrianto, md, fiha.pdf

CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

Post Resuscitation Syndrome“Restart the heart and keep it restarted”

AndriantoRuthvi Adriana


Scenario

45 y.o man admitted to the ER

Chief complaint : ischemic chest pain since an

hour ago, ST elevation in ECG.

Immediately unconscious with ventricle

fibrillation in ECG monitoring

CPR was performed and ROSC in 10 minutes


Patient is ROSC

What’s happen?


Post Resuscitation Syndrome

To minimizeBrain injury

To correctMyocardial dysfunction

To manageSystemic ischemia -

reperfusion response

To detect and treatPersistent precipitating

pathology

Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)


Not only

Return of Spontaneous Circulation (ROSC)

but

Return to Pre Arrest Status


Post Resuscitation Syndrome

To minimizebrain injury

To correctmyocardial dysfunction

To managesystemic ischemia -

reperfusion response

To detect and treatpersistent precipitating

pathology



Our approach should be:

Comprehensive

Structured

Multidisciplinary system of care


ManagementROSC

In field: - Maintain C-A-B - Oxygenation- IV access - ECG 12 leads- Monitor rhythms

In ED & ICU: Access vital sign, airway, and mental status

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.


Patient comatose

• Focused history and physical examination• Laboratory & imaging examination

• Initiate cardiopulmonary and metabolic stabilization•Treat precipitating cause

Multidisciplinary System of Care

Patient non comatose

Therapeutichypothermia




Ventilation

Cardiovascular and Hemodynamic

Metabolic

Neurological



Ventilation

• Maintain good airway

• Adequate oxygenation and ventilation

• Intubation if needed

• Avoid hypo-hyperventilation

• Reduce FIO2 as tolerated → SPO2 ≥94%

• PaCO2 40–45 mm hg




Ventilation


Metabolic

Neurological



Cardiac and Hemodynamic

Maintain adequate tissue perfusion and prevent recurrent

hypotension (MAP 65 - 75 mm Hg; TDS >90 mm Hg)

Consider iv hydration with isotonic fluids and pressor support

Continues cardiac monitoring

Treat coronary ischemia with reperfusion

Treat arrhythmias as appropriate




Ventilation


Metabolic

Neurological



Metabolic• Frequent electrolyte monitoring

• Adequate repletion of K, Mg to keep K › 3.5 mEq/L

• Treat hypo-hyperkalemia

• Avoid hypo/hyperglycaemia (target glucose 144–180 mg/dL)

• Monitor urine output




Ventilation


Metabolic

Neurological



Neurological

Baseline neurological examination

Imaging of brain to assess for ischemia / haemorrhage

if clinically indicated

EEG to assess subclinical seizures

Therapeutic hypothermia



Benson et al,Anesth Analg 1959; 38: 423-8.

Comatose survivors

Asystole or VF

31-32°C

Cooling until neurologic recovery(3 hours to 8 days)

Water-filled blanket

0102030405060

Favorable neurologicrecovery

%

Hypothermia (n=12)

Normothermia (n=7)

The Use of HypothermiaAfter Cardiac Arrest


Hypothermia

Normothermia

P 0.02

Mild therapeutic hypothermia to improve the neurologic outcome after cardiacarrest. N Engl J Med. 2002;346:549-556.

Mild therapeutic hypothermiato improve the neurologic outcome


Cooling Technique

Cooling blankets

Ice / cold liquid packing

Ice / cold liquid gastric lavage

IV cooling catheter

Cooling mist

Other method

0% 10% 20% 30% 40% 50%

Cooling technique Percentage of respondents

50%

15%

13%

2%

2%

17%


Coolong Blankets


Basics of Therapeutic Hypothermia:Three phases of treatment

Induction Rapidly bring the temperature to 32-34C Sedate with propofol or midazolam during TH Paralyze to suppress heat production

Maintenance The goal temperature at 33C Standard 12-24 hours (optimal duration is unknown) Suppress shivering

Rewarming Most dangerous period: hypotension, brain swelling, Goal is to reach normal body temperature over 12-

24h Stop all sedation when normal body temperature is

achieved


Monitoring:

Seizure, shivering

Aritmia & unstable hemodinamic → rewarmed

Electrolyte imbalance (Mg,K,P,Ca,Na ↓)

Temperature check, skin care

Bleeding , dehydration, infection



The 2005 AHA guidelines:

Comatose, ventricular fibrillation (VF) (class IIA)

Comatose, other rhythms (class IIB)



Prognostication

Pre-Arrest

o Age

o Comorbidities

Arrest

o Collapse to CPR time

o Prolonged CPR

o Initial Rhythm

o CPR quality

Post - arrest

o Clinical examination

o EEG

o Somatosensory

evoked potential

o Neurological

biochemical marker



Summary

The rate of ROSC continues to increase and proper post-

resuscitation care could reduce mortality and morbidity.

Managing the ROSC patients requires a multidisciplinary

system of care: including ventilation, cardiac, hemodynamic,

metabolic, and neurological approach.

Strong evidence that hypothermia theraupetic is neuro-

protective after return of spontaneous circulation


Thank You


Outcomes of Therapeutic Hypothermia

Alive at hospital discharge - favorable neurological recovery

Alive at 6 months - favorable neurological recovery

Hypothermia NormothermiaHACA Study Group 72/136 (53%) 50/137 (36%)

Bernard 21/43 (49%) 9/34 (26%)

Hachimi-Idrissi 4/16 (25%) 1/17 (6%)

Hypothermia NormothermiaHACA Study Group 72/136 (52%) 50/137 (36%)

post resuscitation syndrome - andrianto, md, fiha.pdf

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