1. Post resuscitation care involves not only return of spontaneous circulation but return to pre-arrest status through management of global ischemia, cardiovascular dysfunction, and persistent precipitant causes. 2. Immediate goals after ROSC include optimization of cardiovascular function and oxygen delivery, ventilation support, temperature management, etiology investigation, and interventions to prevent recurrence. 3. Prognostication is an essential component using markers like neurological exams, EEGs, imaging and biomarkers to predict outcomes in comatose post-cardiac arrest patients.

1. Post Resuscitation Care
Dr.Joseph Rajesh
HOD
Dept of Anesthesiology
Indira Gandhi Medical College & RI
Puducherry

2. Got back
ROSC ?

3. Not only
Return of Spontaneous Circulation (ROSC)
But
Return of Pre Arrest Status (ROPAS)

4. To correct
To minimize
Cardiovascular
Brain injury
dysfunction
PCAS
To Manage To Detect &Treat
Persistant
Global ischemia Precipitant
& Reperfusion cause

6. Cardiovascular
Brain injury
dysfunction
PCAS
Persistant
Global ischemia Precipitant
& Reperfusion cause

7. ROSC
Immediate
20 minutes
Early
Life support
6 Hours
8 Hours
Prevent Recurrence
Intermediate
24 Hours
Prognostication
Recovery
72 Hours
Rehabilitation

8. 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

9. ROSC
Immediate
Multiple Tasks 20 minutes
Etiology
Early
Search 8 Hours
optmizing
Hemo Investigations
Intermediate
Life support
dynamics
24 Hours
Supportive
care
Prevent Recurrence
Recovery
Prognostication
72 Hours
Ventilatory
Support Interventions
Rehabilitation

10. Optimization of Cardio Vascular function
End
Organ
perfusion
Oxygen delivery
Perfusion pressure
Intra vascular volume

11. 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

12. Ventilatory
Support
Pulmonary Respiratory
dysfunction Support
To
Pulmonary
Unload
edema Aspiration Atelectasis Respiratory
demand

13. Strategies
Hypoxia
Hyperoxia

14. 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

15. To ensure Oxygen delivery:
• Mixed/ central venous
oxygen saturation
– > 70 %
– <70%
• Aggressive Resuscitation
• Dobutamine
• Sr.Lactate
– Serial vlaues
– 10% clearence

16. Etiology
Search

17. Monitoring/Investigations

18. Interventions
Targeted Temperature
management

19. Why ?

20. Hypothermia
• Who ?
– comatose (usually defined as a lack of meaningful
response to verbal commands) after ROSC.
• How long ?
– 12- 24 hours

21. How much ?

22. 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.

23. How ?
External Internal

24. 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

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

27. Interventions
• Coronary revascularization:
– All patients with STEMI/New LBBB
• Coronary catheterization:
– Ongoing hemodynamic instability
• Increasing biomarkers
• Regional wall motion abnormalities

28. Interventions
• Glucose Control:
– Hyperglycemia after arrest is detrimental
• Intensive therapy Hypoglycemnia
• Hypoglecemia Worse outcome
– Target Values 144 – 180 mg%

29. 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

30. Supportive care
• Seizure control
– EEG as soon as possible
– All comatose patients
– Myoclonus:
– Clonazepam
– General Seizures
– Benzodiazepines
– Barbiturates
– Phenytoin
– Propofol

31. 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

32. 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

33. 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

34. 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)

35. 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

36. 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)

37. Summary

38. 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