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Post resuscitation care

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Post resuscitation care

  1. 1. Post Resuscitation Care Dr.Joseph Rajesh HOD Dept of Anesthesiology Indira Gandhi Medical College & RI Puducherry
  2. 2. Got backROSC ?
  3. 3. Not only Return of Spontaneous Circulation (ROSC) ButReturn of Pre Arrest Status (ROPAS)
  4. 4. To correct To minimize Cardiovascular Brain injury dysfunction PCASTo Manage To Detect &Treat PersistantGlobal ischemia Precipitant& Reperfusion cause
  5. 5. Cardiovascular Brain injury dysfunction PCAS PersistantGlobal ischemia Precipitant& Reperfusion cause
  6. 6. ROSC Immediate20 minutes Early Life support 6 Hours 8 Hours Prevent Recurrence Intermediate 24 Hours Prognostication Recovery 72 Hours Rehabilitation
  7. 7. ROSC Immediate 20 minutes Early• Follow 6 Hours A Intermediate Life support 24 Hours B Prevent Recurrence Recovery Prognostication 72 Hours C Rehabilitation Base line neurological evaluation
  8. 8. ROSC Immediate Multiple Tasks 20 minutes Etiology Early Search 8 Hoursoptmizing Hemo Investigations Intermediate Life support dynamics 24 Hours Supportive care Prevent Recurrence Recovery Prognostication 72 HoursVentilatory Support Interventions Rehabilitation
  9. 9. Optimization of Cardio Vascular function End Organ perfusion Oxygen delivery Perfusion pressure Intra vascular volume
  10. 10. ROSC CV system Optimization 20 minutes Immediate ( MAP >65 mmHg) Early– Convert IO lines 8 Hours– Intra Venous Fluids • Fluid boluses if tolerated Intermediate Life support • Avoid 24 Hours – Dextrose containing Prevent Recurrence – Hypotonic fluids Recovery Prognostication • RL preferred ( 1-2 L) 72 Hours– Vasoactive agents • Epinephrine • Dopamine Rehabilitation • Nor Epinephrine MAP of 80-100 for optimal cerebral perfusion
  11. 11. Ventilatory Support Pulmonary Respiratory dysfunction Support ToPulmonary Unload edema Aspiration Atelectasis Respiratory demand
  12. 12. Strategies HypoxiaHyperoxia
  13. 13. Ventilatory Support• Goals: – SpO2 ~ 94-99 % – PaCO2 - 40 -45 mmHg.• How? – Titrate FiO2 – Set Tidal volume of 6-7 ml/kg – 10 -12 breath/mt
  14. 14. To ensure Oxygen delivery:• Mixed/ central venous oxygen saturation – > 70 % – <70% • Aggressive Resuscitation • Dobutamine• Sr.Lactate – Serial vlaues – 10% clearence
  15. 15. Etiology Search
  16. 16. Monitoring/Investigations
  17. 17. InterventionsTargeted Temperature management
  18. 18. Why ?
  19. 19. Hypothermia• Who ? – comatose (usually defined as a lack of meaningful response to verbal commands) after ROSC.• How long ? – 12- 24 hours
  20. 20. How much ?
  21. 21. 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.
  22. 22. How ?External Internal
  23. 23. Monitoring Complications • Best: – esophageal, bladder (non • Arrhythmias anuric patients) PA , hyperglycemia, Impaired coagulation • Inadequate: – with an unintended drop below target – Oral, axillary, Rectal • High infection rate
  24. 24. PRINCE Trial• Pre Rosc Intra Nasal Cooling Effectiveness – Perflurocarbon into nasal cavity – Targeted cooling of cerebral structure
  25. 25. Interventions• Coronary revascularization: – All patients with STEMI/New LBBB• Coronary catheterization: – Ongoing hemodynamic instability • Increasing biomarkers • Regional wall motion abnormalities
  26. 26. Interventions• Glucose Control: – Hyperglycemia after arrest is detrimental • Intensive therapy Hypoglycemnia • Hypoglecemia Worse outcome – Target Values 144 – 180 mg%
  27. 27. 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
  28. 28. Supportive care• Seizure control – EEG as soon as possible – All comatose patients – Myoclonus: – Clonazepam – General Seizures – Benzodiazepines – Barbiturates – Phenytoin – Propofol
  29. 29. 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
  30. 30. Supportive care• Neuroprotective drugs – Drugs tried • Thiopentone,Glucocorticoids, nimodipine, lidoflazine,benzod iazepines, magnesium, coenzyme Q10 – Present status • No benefit• Future Agents: • Xenon • Erythropoietin • Hydrogen sluphide
  31. 31. ROSC Immediate Prognostication 20 minutes Early• Essential component of 6 Hours post cardiac arrest care. Intermediate Life support 24 Hours Prevent Recurrence Prognostication Recovery 72 Hours Rehabilitation
  32. 32. 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)
  33. 33. 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
  34. 34. 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)
  35. 35. Summary
  36. 36. 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

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