Postresuscitation Support

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Postresuscitation Support

• 2005 American Heart Association Guidelines for
  Cardiopulmonary Resuscitation and Emergency
  Cardiovascular Care

4C1 Ri ???
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Initial Objectives

• Optimize cardiopulmonary function and systemic
  perfusion (brain)
• Try to identify the precipitating causes of the
  arrest.
• Prevent recurrence
• Improve long-term, neurologically intact survival.

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Temperature RegulationGlucose ControlOrgan-Speci
fic Evaluation and SupportRespiratory
systemCardiovascular systemCentral nervous
system
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Hypothermia

• Goal 3234oC for 1224 hours
• Mild hypothermia may be beneficial to
  neurological outcome.
• Well tolerated without significant risk of
  complications.

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Hypothermia

• Permissive hypothermia
• Allowing a mild degree of hypothermia gt33oC
  that often develops spontaneously after arrest
• Induced hypothermia
• Cooling within minutes or hours after ROSC.

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Methods

• External cooling techniques
• Cooling blankets ice bags.
• Require several hours to attain target BT
• Internal cooling techniques
• Cold saline, endovascular cooling catheter.

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Complications

• Coagulopathy
• Arrhythmia
• (unintentional drop below target BT)
• Pneumonia, sepsis
• Hyperglycemia

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Subset of Patient

• Initially comatose but hemodynamically stable
  after a witnessed arrest of presumed cardiac
  etiology. (Class IIa)
• Non-VF arrest out-of-hospital (Class IIb)
• In-hospital arrest. (Class IIb)
• Asphyxiated neonates.

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Hyperthermia

• Significance imbalance between oxygen supply and
  demand gt impair brain recovery.
• A symptom of brain injury.
• Difficult to control it with conventional
  antipyretics.

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Glucose Control

• Strong association between high blood glucose and
  poor neurological outcome.
• But control of serum glucose not necessary alters
  outcome.

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Glucose Control

• Goal 58mmol/L (90145mg/dL)
• In comatose patients, signs of hypoglycemia are
  less apparent.

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Organ - Specific Support

• Prevent, detect, and treat hypoxemia and
  hypotension because these conditions can
  exacerbate brain injury.

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Respiratory System

• Debate exists as to the length of time patient
  who require ventilatory support should remain
  sedated.
• Sedative drugs (Propofol, Dormicum)
• Neuromuscular blockage. (Nimbex)

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• Sedation may be necessary to control shivering
  during hypothermia.
• Neuromuscular blockade should be kept be minimum
  because these agents preclude thorough neurologic
  assessment.

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Ventilatory Parameters

• Sustained hypocapnia may reduce cerebral blood
  flow.
• Hyperventilation
• Cerebral vasoconstriction
• Decrease CBF
• May worsen neurologic outcome

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• Hyperventilation
• Generates increased airway pressures
• Augment intrinsic PEEP
• cerebral venous pressure?
• ICP?
• CBF?
• brain ischemia

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• Ventilation to normocarbic level is appropriate.
• Routine hyperventilation is detrimental (Class
  III)

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Cardiovascular System

• Ischemia/reperfusion of cardiac arrest
• Electrical defibrillation
• Significant early but reversible myocardial
  dysfunction.
• Low cardiac output
• Followed by later vasodilation.

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Cardiovascular System

• Volume
• Vasoactive drugs (ex. Levophed)
• Inotropics (ex. Dopamine)
• Inodilator (ex. Milrinone)
• To support BP, cardiac index, and systemic
  perfusion.

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Adrenal Insufficiency

• Relative adrenal insufficiency may develop
  following the stress of cardiac arrest.
• Early corticosteroid supplementation to improve
  outcome is unproven.

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Antiarrhythmics

• There is insufficient evidence to recommend for
  or against prophylactic antiarrhythmic drugs.
• ICD
• Beta-blocker
• Amiodarone

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Implantable Cardioverter Defibrillator

• The ICD extended survival by a mean of 4.4 months
  during a follow up period of 6 years.
• Patient with a LVEFlt35 derived significant more
  benefit from ICD.

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Beta-blockers

• The use of beta-blocker seems prudent if there
  are no contraindication. (when therapeutic
  hypothermia because of relative HR?)
• Indication
• Known or recent MI and/or HF.
• Cardiac arrest of presumed cardiac etiology

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Amiodarone

• A significant reduction in total mortality and a
  reduction in antiarrhythmic death.
• Indication
• Recurring ventricular arrhythmias despite
  beta-blockade or if beta-blockade is not
  tolerated.

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Central Nervous System

• Optimize CPP
• Normal or slightly elevated MAP
• Reducing ICP

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Central Nervous System

• Hyperthermia and seizures increase the oxygen
  requirement of the brain .
• Treat hyperthermia.
• Consider therapeutic hypothermia.

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Seizure

• Witnessed seizures should be promptly controlled
  and maintenance anticonvulsant therapy initiated.
  
• (Class IIa)
• Routine seizure prophylaxis
• (Class Indeterminate)

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Prognostic Factors - 1

• Median nerve somatosensory-evoked potentials
  measured 72 hours after cardiac arrest
• Predict neurological outcome in patients with
  hypoxic-anoxic coma.

Cerebral microvessel response to focal ischemia.
J Cereb Blood Flow Metab. 2003
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Prognostic Factors - 2

• Absent corneal reflex at 24 hrs.
• Absent pupillary response at 24 hrs.
• Absent withdrawal response to pain at 24 hrs.
• No motor response at 24 hrs.
• No motor response at 72 hrs.

Is this patient dead, vegetative, or severely
neurologically impaired? Assessing outcome for
comatose survivors of cardiac arrest. JAMA. 2004
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Prognostic Factors- 3

• An electroencephalogram performed gt 24 to 48
  hours after resuscitation has also been shown to
  provide useful predictive information.

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Prognostic Factors - 4

• High serum lactate (gt10.0mmol/L)
• High P(a-et)CO2 (gt12.5mmHg)
• High VdA/Vt (gt0.348)
• During early ROSC in cardiac arrest patients
  suggest high hospital mortality.

Arterial minus end-tidal CO2 as a prognostic
factor of hospital survival in patients
resuscitated from cardiac arrest. Resuscitation.
2007
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37.545mmHg
90145mg/dL
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Conclusion

• The goal of the postresuscitation period is to
  manage vital signs, lab abnormalities, and
  support organ system function to increase the
  likelihood of intact neurologic survival.

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Reference

• Post Resuscitation Care. What Are the Therapeutic
  Alternatives and What Do We Know? J. Herlitz et
  al. Resuscitation (2006) 69, 15-22
• Implementation of A Standardised Treatment
  Protocol for Post Resuscitation Care after
  Out-of-hospital Cardiac Arrest. Kjetil Sunde et
  al. Resuscitation (2007)