Chapter 13. Post resuscitation care

Post-resuscitation care is a critical phase following the return of spontaneous circulation (ROSC) after cardiac arrest. While achieving ROSC is an essential step, the ultimate goal is to restore normal cerebral function, maintain stable cardiac rhythm, and ensure haemodynamic stability. The quality of care in this phase significantly influences long-term patient outcomes.

This phase of care starts immediately at the site of ROSC and continues after the patient is transferred to an intensive care unit (ICU) or coronary care unit (CCU) for ongoing monitoring and treatment.

The Post-Cardiac Arrest Syndrome

Post-cardiac arrest syndrome (PCAS) consists of four major components:

1. Post-cardiac arrest brain injury – Can result in coma, seizures, cognitive dysfunction, or brain death.
2. Post-cardiac arrest myocardial dysfunction – Often recovers within 2-3 days but requires haemodynamic support.
3. Systemic ischaemia/reperfusion response – Similar to sepsis, leading to vasodilation, endothelial injury, and increased risk of infection.
4. Persistent precipitating pathology – Includes underlying conditions like myocardial infarction (MI), pulmonary embolism, or hypoxia that triggered the arrest.

The severity of PCAS depends on the duration and cause of cardiac arrest. Prolonged cardiac arrest increases the risk of severe brain injury and multi-organ failure.

Post-Resuscitation Care Algorithm

Immediate Priorities After ROSC (ABCDE Approach)

1. Airway & Breathing:
   • Oxygen therapy to maintain SpO₂ at 94-98% (avoiding hypoxia and hyperoxia).
   • Consider intubation and ventilation in patients with altered mental status.
   • Maintain normocapnia (PaCO₂: 4.6–6.0 kPa).
2. Circulation:
   • Maintain systolic BP ≥100 mmHg to ensure cerebral and myocardial perfusion.
   • Use 250 mL IV fluid boluses (0.9% saline) for hypotension.
   • Consider vasopressors (e.g., noradrenaline) if fluids alone are insufficient.
3. Disability & Neurological Function:
   • Assess Glasgow Coma Scale (GCS) to evaluate brain function.
   • Consider Targeted Temperature Management (TTM) for comatose patients.
4. Exposure & Further Management:
   • Identify precipitating causes (e.g., STEMI, pulmonary embolism, sepsis).
   • Transfer to a cardiac arrest centre if required for coronary angiography and PCI.

Haemodynamic Support in Post-Resuscitation Care

Hypotension is common after ROSC due to myocardial dysfunction. The goals are:

• Maintain mean arterial pressure (MAP) at 65-70 mmHg.
• Use IV fluids (250-500 mL saline or Ringer’s lactate) for volume resuscitation.
• Use inotropes and vasopressors (e.g., noradrenaline) if fluid resuscitation fails.
• Consider echocardiography to assess cardiac function.

Targeted Temperature Management (TTM)

TTM (formerly called therapeutic hypothermia) improves neurological outcomes in comatose post-cardiac arrest patients.

Guidelines for TTM:

• Maintain body temperature at 32-36°C for at least 24 hours.
• Use external cooling devices (cooling blankets, ice packs) or IV cold saline.
• Avoid hyperthermia (>37.5°C), as it worsens brain injury.
• After 24 hours, rewarm the patient slowly to prevent cardiovascular instability.

Neurological Prognostication

Assessing prognosis in comatose post-arrest patients is challenging and should be delayed until at least 72 hours after ROSC.

Methods of Prognostication:

1. Clinical Examination:
   • Pupil and corneal reflexes
   • GCS assessment
   • Myoclonus status epilepticus
2. Neurophysiological Tests:
   • EEG (Electroencephalography) to detect brain activity.
   • SSEPs (Somatosensory Evoked Potentials) to assess cortical response.
3. Biochemical Markers:
   • Neuron-Specific Enolase (NSE) for neuronal damage.
4. Imaging:
   • CT or MRI scan to detect structural brain injury.

Oxygenation & Ventilation Strategy

• Avoid hypoxia (PaO₂ <8 kPa) and hyperoxia (PaO₂ >16 kPa) to prevent brain damage.
• Maintain end-tidal CO₂ at 4.6-6.0 kPa using capnography.
• Switch from manual to mechanical ventilation for controlled respiratory support.

Glucose Control

• Maintain blood glucose ≤10 mmol/L to avoid hyperglycaemia.
• Prevent hypoglycaemia (<4.0 mmol/L), which increases mortality.

Transport & Cardiac Arrest Centres

Patients who achieve ROSC should be transferred to a specialist cardiac arrest centre (CAC).

• CACs provide coronary angiography, PCI, and intensive post-arrest care.
• Immediate PCI is recommended for STEMI patients post-arrest.

Rehabilitation & Long-Term Care

• 50% of cardiac arrest survivors have cognitive impairments (memory loss, executive dysfunction).
• Neurological rehabilitation should be considered.
• Emotional and psychological support is crucial for survivors and families.

Organ Donation Considerations

Patients who do not survive post-resuscitation care may become organ donors. Studies show that organ survival rates from post-cardiac arrest donors are comparable to other donors.

🔹 Key Takeaways from Post-Resuscitation Care

✔ Post-cardiac arrest syndrome includes brain injury, myocardial dysfunction, and systemic inflammation.
✔ Oxygenation should be titrated to SpO₂ 94-98%, avoiding hyperoxia.
✔ Targeted Temperature Management (32-36°C) is recommended for comatose survivors.
✔ Prognostic assessment should be multimodal and delayed for at least 72 hours.
✔ Patients with STEMI should be transported to a cardiac arrest centre for PCI.
✔ Rehabilitation is essential due to common cognitive impairments post-arrest.
✔ Organ donation should be considered in non-survivors.