Post Cardiac Arrest Syndrome

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Post-Cardiac Arrest Syndrome:
Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation
Circulation. 2008;118:2452-2483

Published in: Health & Medicine

Post Cardiac Arrest Syndrome

  1. 1. ILCOR Consensus StatementPost-Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and PrognosticationA Consensus Statement From the International Liaison Committee on Resuscitation<br />Circulation. 2008;118:2452-2483<br />
  2. 2. Background<br />Cardiopulmonary Resuscitation (CPR)<br />Resumption of Spontaneous Circulation (ROSC)<br />Resuscitation<br />Post-CardiacArrest Syndrome (PCAS)<br />
  3. 3. Epidemiology<br />The largest published in-hospital cardiac arrest database (theNRCPR) includes data from >36000 cardiac arrests.<br />In-hospital mortalityrate was 67% for the 19819 adults with any documented ROSC,<br />62% for the 17183 adults with ROSC >20 minutes.<br />
  4. 4. Phases of post-cardiac arrest syndrome.<br />
  5. 5. Pathophysiology of <br />Post–Cardiac Arrest Syndrome<br />
  6. 6. Post-Cardiac Arrest Brain Injury<br />Triage Systems in the United States<br />
  7. 7. Post–Cardiac Arrest Myocardial Dysfunction<br />Triage Systems in the United States<br />
  8. 8. Systemic Ischemia/Reperfusion Response<br />Triage Systems in the United States<br />
  9. 9. Persistent Precipitating Pathology<br />Triage Systems in the United States<br />
  10. 10. Therapeutic Strategies<br />Monitoring<br />Early Hemodynamic Optimization<br />Ventilation<br />Circulatory Support<br />Management of ACS<br />Therapeutic Hypothermia<br />Sedation and Neuromuscular Blockade<br />Seizure Control and Prevention<br />Glucose Control<br />Placement of Implantable Cardioverter-Defibrillators<br />
  11. 11. Monitoring Options<br />General intensive care monitoring     <br />Arterial catheter<br />Oxygen saturation by pulse oximetry     <br />Continuous ECG    <br />CVP     <br />ScvO2     <br />Temperature (bladder, esophagus)     <br />Urine output     <br />Arterial blood gases     <br />Serum lactate     <br />Blood glucose, electrolytes, CBC, and general blood sampling     <br />Chest radiograph<br />More advanced hemodynamic monitoring     <br />Echocardiography     <br />Cardiac output monitoring (either noninvasive or PA catheter) <br />Cerebral monitoring     <br />EEG (on indication/continuously): early seizure detection and treatment <br />CT/MRI<br />
  12. 12. Early Hemodynamic Optimization<br />Early Goal-Directed Therapy<br />CVP: 8 to 12 mm Hg, <br />MAP: 65 to 90 mm Hg, <br />ScvO2 >70%, <br />Hematocrit >30% or hemoglobin >8 g/dL, <br />lactate <2mmol/L, <br />urine output >0.5 mL · kg–1 · h–1, <br />oxygen deliveryindex >600 mL · min–1 · m–2<br />
  13. 13.
  14. 14. VentilationSurviving Sepsis CampaignRecommends:<br />
  15. 15. Circulatory Support<br />Dysrhythmias can be treated by maintenance of normal electrolyteconcentrations, use of standard drug and electrical therapies.<br />The first-line intervention for hypotension is to optimize right-heart filling pressures by use of IV fluids. In 1 study,3.5 to 6.5 L of IV crystalloid was required in thefirst 24 hours after ROSC after OHCAto maintain CVP in the range of 8 to 13 mmHg.<br />
  16. 16. Circulatory Support<br />Inotropes and vasopressors should be considered if hemodynamicgoals are not achieved despite optimized preload.<br />Early echocardiography willenable the extent of myocardial dysfunction to be quantifiedand may guide therapy. <br />Additionalcardiac support: intra-aorticballoon pump (IABP), percutaneous cardiopulmonary bypass, extracorporeal membraneoxygenation (ECMO), transthoracic ventricular assist devices.<br />
  17. 17. Management of ACS<br />Patients resuscitated from cardiac arrest who have ST-elevation myocardial infarctionshould undergo immediate coronary angiography, with subsequentPCI if indicated.<br />It is appropriate toconsider immediate coronary angiography in all post–cardiacarrest patients in whom ACS is suspected.<br />
  18. 18. Therapeutic Hypothermia<br />Unconscious adult patientswith ROSC after out-of-hospital VF cardiacarrest should be cooled to 32°C to 34°C for at least12 to 24 hours.<br />Rapid IV infusion of ice-cold 0.9% salineor Ringer’s lactate (30 mL/kg) is a simple, effectivemethod for initiating cooling.<br />Slow rewarming: 0.25°C to 0.5°C per hour.<br />If therapeutic hypothermia is not undertaken, pyrexia duringthe first 72 hours after cardiac arrest should be treated aggressivelywith antipyretics or active cooling.<br />
  19. 19. Sedation and Neuromuscular Blockade<br />Critically ill post–cardiac arrest patientswill require sedation for mechanical ventilation and therapeutichypothermia. <br />Adequate sedation is particularly important for prevention ofshivering during induction of therapeutic hypothermia, maintenance,and rewarming.<br />
  20. 20. Seizure Control and Prevention<br />Prolonged seizures may cause cerebral injury andshould be treated promptly and effectively with benzodiazepines,phenytoin, sodium valproate, propofol, or a barbiturate.<br />Clonazepam is the drug of choice for the treatmentof myoclonus. <br />
  21. 21. Glucose Control<br />Tight control blood glucose (80 to 110mg/dL) with insulin reduced hospital mortality rates in criticallyill adults.<br />
  22. 22. Placement of Implantable Cardioverter-Defibrillators<br />In survivors with good neurological recovery, insertion of anICD is indicated if subsequentcardiac arrests cannot be reliably prevented by other treatments(such as pacemaker for AV block, transcatheterablation of a single ectopic pathway, or valve replacement forcritical aortic stenosis).<br />

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