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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
L
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Pr
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• Follow
ABC
Immediate
Early
Recovery
Rehabilitation
ROSC
Intermediate
20 minutes
6 Hours
24 Hours
72 Hours
L
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Base line neurological evaluation
Multiple Tasks Immediate
Early
Recovery
Rehabilitation
ROSC
Intermediate
20 minutes
8 Hours
24 Hours
72 Hours
L
ife s
uppo
rtPr
ogno
stica
tion
Pr
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t Re
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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
L
ife s
uppo
rtPr
ogno
stica
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Pr
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t Re
curr
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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
L
ife s
uppo
rtPr
ogno
stica
tion
Pr
even
t Re
curr
ence
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
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