Post Resuscitation Syndrome

Post Resuscitation Syndrome
Restart the heart and keep it restarted
Andrianto
Ruthvi Adriana
CARDIOVASCULAR EMERGENCIES COURSE
Bumi Surabaya Hotel, November 7-8th, 2015
Scenario
45 y.o man admitted to the ER
Chief complaint : ischemic chest pain since an
hour ago, ST elevation in ECG.
Immediately
unconscious
with
ventricle
fibrillation in ECG monitoring
CPR was performed and ROSC in 10 minutes

Patient is ROSC
Whats happen?

To minimize
Brain injury
To correct
Myocardial dysfunction
To manage
Systemic ischemia reperfusion response
To detect and treat

Persistent precipitating
pathology
Robert W. Neumar et al. 2008. PostCardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
Not only
Return of Spontaneous Circulation (ROSC)
but
Return to Pre Arrest Status

To minimize
brain injury
To correct
myocardial dysfunction
To manage
systemic ischemia reperfusion response
To detect and treat

persistent precipitating
pathology
Our approach should be:

Comprehensive
Structured
Multidisciplinary system of care
Management
ROSC
In field: - Maintain C-A-B - Oxygenation

- IV access
- ECG 12 leads
- Monitor rhythms
In ED & ICU: Access vital sign, airway, and mental status
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
Patient comatose
Patient non comatose
Therapeutic
hypothermia
Focused history and physical examination

Laboratory & imaging examination
Initiate cardiopulmonary and metabolic stabilization
Treat precipitating cause
Multidisciplinary System of Care


Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological

Ventilation
Metabolic
Neurological
Ventilation
Maintain good airway
Adequate oxygenation and ventilation
Intubation if needed
Avoid hypo-hyperventilation
Reduce FIO2 as tolerated SPO2 94%
PaCO2 4045 mm hg

Ventilation
Metabolic
Neurological
Cardiac and Hemodynamic

Maintain adequate tissue perfusion and prevent recurrent
hypotension (MAP 65 - 75 mm Hg; TDS >90 mm Hg)
Consider iv hydration with isotonic fluids and pressor support
Continues cardiac monitoring
Treat coronary ischemia with reperfusion
Treat arrhythmias as appropriate

Ventilation
Metabolic
Neurological
Metabolic
Frequent electrolyte monitoring
Adequate repletion of K, Mg to keep K 3.5 mEq/L
Treat hypo-hyperkalemia
Avoid hypo/hyperglycaemia (target glucose 144180 mg/dL)
Monitor urine output

Ventilation
Metabolic
Neurological
Neurological
Baseline neurological examination
Imaging of brain to assess for ischemia / haemorrhage
if clinically indicated
EEG to assess subclinical seizures

Therapeutic hypothermia
The Use of Hypothermia

After Cardiac Arrest
60
50
Comatose survivors
Asystole or VF
40
% 30
20
10
31-32C
Cooling until neurologic recovery
Favorable neurologic
recovery
(3 hours to 8 days)
Hypothermia (n=12)
Water-filled blanket
Normothermia (n=7)
Benson et al,Anesth Analg 1959; 38: 423-8.
Mild therapeutic hypothermia

to improve the neurologic outcome
P 0.02
Hypothermia
Normothermia
Mild therapeutic hypothermia to improve the neurologic outcome after cardiac

arrest. N Engl J Med. 2002;346:549-556.
Cooling Technique
Cooling technique
Percentage of respondents
0%
Cooling blankets
Ice / cold liquid packing
Ice / cold liquid gastric lavage
IV cooling catheter
Cooling mist
Other method
10%
20%
30%
40%
50%
50%
15%
13%
2%
2%
17%
Coolong Blankets
Basics of Therapeutic Hypothermia:

Three phases of treatment
Induction
Rapidly bring the temperature to 32-34C
Sedate with propofol or midazolam during TH
Paralyze to suppress heat production
Maintenance
The goal temperature at 33C
Standard 12-24 hours (optimal duration is unknown)
Suppress shivering
Rewarming
Most dangerous period: hypotension, brain swelling,
Goal is to reach normal body temperature over 1224h
Stop all sedation when normal body temperature is
achieved
Monitoring:
Seizure, shivering
Aritmia & unstable hemodinamic rewarmed
Electrolyte imbalance (Mg,K,P,Ca,Na )
Temperature check, skin care
Bleeding , dehydration, infection
The 2005 AHA guidelines:
Comatose, ventricular fibrillation (VF) (class IIA)

Comatose, other rhythms (class IIB)
Prognostication
Pre-Arrest
Arrest
Post - arrest
o Age
o Collapse to CPR time
o Clinical examination
o Comorbidities
o Prolonged CPR
o EEG
o Initial Rhythm
o Somatosensory
o CPR quality
evoked potential
o Neurological
biochemical marker
Summary
The rate of ROSC continues to increase and proper postresuscitation care could reduce mortality and morbidity.
Managing the ROSC patients requires a multidisciplinary

system of care: including ventilation, cardiac, hemodynamic,
metabolic, and neurological approach.
Strong evidence that hypothermia theraupetic is neuroprotective after return of spontaneous circulation
Thank You
Outcomes of Therapeutic Hypothermia
Alive at hospital discharge - favorable neurological recovery

Hypothermia
Normothermia
HACA Study Group
72/136 (53%)
50/137 (36%)
Bernard
21/43 (49%)
9/34 (26%)
Hachimi-Idrissi
4/16 (25%)
1/17 (6%)
Alive at 6 months - favorable neurological recovery

HACA Study Group
Hypothermia
Normothermia
72/136 (52%)
50/137 (36%)

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Restart the heart and keep it restarted

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

fibrillation in ECG monitoring

CPR was performed and ROSC in 10 minutes

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015