Module 6: Post-resuscitation care Flashcards
Post-resuscitation care (caring for a patient after ROSC) significantly the chances of achieving a good neurological outcome. The goal of post-resuscitation care is to restore:
- Normal cardiac function
- Stable cardiac rhythm
- Perfusion enough to maintain organ function
- Good quality of life
Post-cardiac arrest syndrome
Occurs after ROSC. Involves multiple body systems. Reflects a state of whole-body ischaemia and subsequent reperfusion.
Manifests as:
1. Post-cardiac arrest brain injury
2. Post-cardiac arrest myocardial dysfunction
3. Systemic ischaemia/reperfusion response
4. Persistence of the precipitating pathology
- Post-cardiac arrest brain injury
This is the cause of death in 68% of patients who have had an out-of-hospital cardiac arrest who have survived to ITU admission.
Post-cardiac arrest brain injury manifests as coma, seizures, myoclonus, varying degrees of neurological dysfunction and brain death.
Tx:
- Maintain autoregulation ie. normocapnia, oxygenation, normoglycaemia, normothermia
- Prevent: hyper/hypocapnia, hypoxia/hyperoxia, hypo/hyperglycaemia, pyrexia and seizures.
- Post-cardiac arrest myocardial dysfunction
Significant myocardial dysfunction is common after cardiac arrest. This is called ‘myocardial stunning’ and may result in a temporary but significantly reduced left ventricular ejection fraction and therefore cardiac output. It typically recovers after 72h.
- Systemic ischaemia/reperfusion response
The whole body ischaemia/reperfusion that occurs after resuscitation from cardiac arrest activates immunological and coagulation pathways that cause multiple organ failure and increase the risk of infection.
The post-cardiac arrest syndrome has many features in common with sepsis, including intravascular volume depletion and vasodilation.
Tx:
- IVF, vasopressors, inotropes
- Maintain end-organ perfusion
- Persistence of the precipitating pathology
Any persisting pathology relating to the cause of the cardiac arrest, such as a myocardial infarction or a pulmonary embolism, will also need treatment.
True/false
All patients require tracheal intubation and ventilation post-arrest to prevent hypoxaemia and hypercarbia?
False
- Spontaneously breathing patients do not require tracheal intubation and ventilation but should be given oxygen by facemask to maintain normal arterial oxygen saturation.
- Consider tracheal intubation, sedation, and controlled ventilation in any patient with obtunded cerebral function
Airway & breathing
Oxygenation:
- Maintain PaO2 94–98%
- Monitor with pulse oximetry & ABG analysis
- Adjust with: inspired oxygen concentration
Carbon dioxide:
- Maintain PaCO2 4.7–6.0 kPa
- Monitor: waveform capnography & ABG analysis
- Adjust: ventilation
Circulation
–Monitor HR, BP, central and peripheral CRT, temp
– Insert a urinary catheter
monitor urine output
(aim ≥ 0.5 mL kg/h)
Monitor end-organ perfusion
Heart -> chest pain
Kidneys -> reduced urine output
Brain -> reduced GCS
Disability
–GCS
–Pupillary response to light
– Limb tone and posture
What is the GCS maximum and minimum score?
Maximum 15
Minimum 3
Further assessment
- History –hospital notes, EMS personnel, family, GP
- Monitoring –pulse, RR, blood pressure (continuous monitoring with arterial line), temp, pulse oximetry, ECG, capnography, urine output
- Investigations – repeat ABGs, 12-lead ECG, CXR, bloods, ECHO
Usefulness of post-resuscitation serial ABGs
- Severity of the likely metabolic, and probably respiratory, acidosis.
- Effectiveness of continued resuscitation can be confirmed by documenting reducing lactate values and correction of base deficit.
- Point of care test for electrolytes such as potassium and sodium.
Usefulness of post-resuscitation bloods
FBC –exclude anaemia (contributes to MI)
Biochemistry, blood glucose, troponin
Transfer of the patient to the ITU (or CCU)
–Discuss transfer with senior members of admitting team
–Full A–E before
– Continue monitoring
Elements of post-resuscitation care on the ITU
- Mechanical ventilation
- Insulin infusion (if needed)
- Intotropes & vasopressors
- IAMP
- Pacing
- Defibrillator
- Enteral nutrition
- Cooling
Mechanical ventilation
Closed breathing system + tracheostomy/tracheal tube
Pts may spontaneously breathe or require degrees of positive pressure ventilatory support)
Aim = normocapnia + normoxia
Insulin infusion
Aim = normoglycaemia (<10.0 but >4.0)
NB: unconscious pts do not display typical symptoms of hypoglycaemia -> potentially fatal
Inotropes & vasopressors
Inotropes = ↑cardiac Output by ↑cardiac contractility
Vasopressors = Vasoconstriction to ↑systemic vascular resistance
Pacing
Patients may require transcutaneous or transvenous pacing.
The electrodes are connected to a pacing monitor, which enables the adjustment of pacing rate and, if necessary, adjustment of current to ensure capture.
Defibrillator
Risk of arrhythmias post-ROSC – leave self-adhesive pads in situ – can terminate arrhythmias via electrical cardioversion
IABP
= Intra-aortic balloon pump
May be inserted post PCI into the aorta, inflating the aorta during diastole, increasing the intra-aortic pressure during diastole & increasing coronary artery perfusion
Cooling
Core temperature is continously monitored post-ROSC.
Aim = normothermia, avoid pyrexia
Enteral nutrition
NG tube.
Body needs energy to counteract the catabolic state ofvpost-cardiac arrest syndrome.
Optimising heart function post-arrest
- Early ECHO
- Arterial line for continuous BP monitoring
- Non-invasive cardiac monitor
- Possible IABP if fluid resus & vasoactive drugs are insufficient to support circulation
- MAP aim should achieve urine output of ≥ 0.5 mL kg-1 h-1 and normal/decreasing plasma lactate
Optimising brain function post-arrest
- Patient is usually sedated with a combination of opioids & hypnotics (short-acting enable earlier neurological assessment.)
- Maintain MAP
- Normoglycaemia (4–10)
- Mild hypothermia (avoid hyperthermia)
- Normocapnia
- Avoid seizures / promptly treat
Temperature control
- Continuously monitor core temperature in comatose post-ROSC patients, avoid pyrexia, avoid fevers!!!
- Do NOT actively warm patients with mild hypothermia
- Treat patients >37º with antipyretics or active cooling (ice packs, wet towels, cooling blankets, water-/air-circulation blankets)
Assessment of prognosis post-arrest?
- Not reliable until >72h
- Delay sufficiently to allow clearance of sedatives & neurological recovery
- No clinical neurological sign which predicts poor outcome so prognostication should be multimodal (incl several modalities)
- Clinical examination – GCS score, pupillary response to light, corneal reflex, presence of seizures.
- Neurophysiological studies – somatosensory evoked potentials (SSEPs) and electroencephalography (EEG).
- Biochemical markers – neuron-specific enolase (NSE) is most commonly used.
- Imaging – CT and MRI brain
