Post Resuscitation Care

Introduction:

Resuscitation means reviving or bringing the patient back into a conscious state by taking action. The main goal of resuscitation in a patient is to attain a return of spontaneous circulation (ROSC). This is done using basic and advanced life support. ROSC helps in improving patient survival with a good quality of life. Therefore, to restrict the gap between ROSC and neurologically intact survival in patients who undergo cardiac arrest, the interventions can be incorporated as post-ROSC interventions.

What Is the Pathophysiology of Post-cardiac Arrest Syndrome?

Cardiac arrest is the sudden and abrupt loss of heart function, breathing, and conscious state. In addition, hypoxia (below normal oxygen level in the blood), ischemia (diminished blood supply to an organ), and reperfusion (restoring blood flow to an organ after a heart attack) that occur during and after the resuscitation phase may damage multiple organ systems.

A condition known as post-cardiac arrest syndrome comprises four major components:

1. Persistent Precipitating Pathology: The most common pathology for cardiac arrest is coronary thrombus (blood clot in the heart’s vessel), which leads to myocardial infarction. Non-coronary causes that may lead to cardiac arrest are hypoxia, pulmonary embolism (PE), and sepsis.

2. Anoxic Brain Injury: After a period of cerebral hypoxia, the reperfusion leads to the formation of free radicals and activation of cell-death signaling pathways. This causes a disturbance in cerebral microvascular homeostasis. This injury can continue from hours to days and is aggravated by fever and poor glucose control. The symptoms are coma, seizures, neurocognitive dysfunction (decreased mental functions), and brain death.

3. Post-cardiac Arrest Myocardial Dysfunction: Despite preserved coronary blood flow, a prominent drop in left ventricular ejection fraction, particularly during the first 24 to 48 hours after ROSC. This manifests as tachycardia (rapid heart rate), hypotension, and poor cardiac output.

4. Systemic Ischaemia/Reperfusion Response: Whole-body hypoxia after ROSC reperfusion results in systemic inflammation and activation of the immunologic and coagulation pathways. Clinical manifestations are fever, altered oxygen consumption, and increased susceptibility to infection.

What Are the Objectives of Post-Cardiac Arrest Care?

• Optimize cardiopulmonary function and vital organ perfusion.

• Transport the in-hospital post-cardiac arrest patient to a critical-care unit.

• Treat the precipitating causes and prevention of recurrent arrest.

• Control body temperature for the optimization of survival and neurological recovery.

• Identification and treatment of acute coronary syndromes (ACS).

• Optimize mechanical ventilation to minimize lung injury.

• Objectively assess the prognosis for recovery.

What Is the Scope of Post-ROSC Care?

Cardiac arrest is multifactorial and can affect multiple organ systems severely regardless of the cause. The following areas need to be taken care of to upgrade outcomes:

1. Identification and treatment of cardiac arrest causes.

2. Management of airway and ventilation.

3. Hemodynamic management to maintain adequate tissue perfusion.

4. Targeted temperature management (TTM) is a controlled therapy in which the body temperature is maintained at a certain point.

5. Glycemic control is a balance of insulin replacement with exercise and diet.

6. Seizure management.

What Are the Steps for the Identification and Treatment of the Cause of Cardiac Arrest?

After ROSC, the factors responsible for cardiac arrest should be identified for appropriate intervention to treat the cause. History of the events that led to the collapse, physical examination, and essential investigation helps to determine the cause. Some commonly known reasons are as follows:

1. Coronary Artery Disease: After ROSC, electrocardiography (ECG) is performed to diagnose myocardial infarction, and an immediate coronary angiography is arranged. Myocardial and neurological functions improve after percutaneous coronary intervention. Hypotensive, despite revascularisation, may need mechanical augmentation through an intra-aortic balloon pump or extracorporeal membrane oxygenation. Emergency coronary angiography follows ROSC in unstable patients with suspected cardiac etiology. Continuous cardiac monitoring for arrhythmias should be managed appropriately.

2. Acute Pulmonary Embolism (APE): This cause indicates poor arterial oxygen saturation following ROSC with appropriate changes in the ECG (electrocardiogram). When direct imaging is not safe because of the patient’s unstable condition, fibrinolytic therapy can be used in post-cardiac arrest patients suspected of having collapsed from severe PE.

3. Cardiotoxic Agent: Drugs such as tricyclic antidepressants, recreational drugs, and cardiac glycosides can lead to cardiac arrest. Though most cardiotoxic drugs are water-soluble and may be excreted by the kidney, therapeutic alkaline diuresis can be done in certain cases. If the agent is known, antidotes are administered. Massive drug overdoses resulting in cardiovascular collapse need rapid removal via hemodialysis.

4. Metabolic Disturbances: Metabolic disorders such as hyperkalemia, hypokalaemia, and hypercalcemia can lead to cardiac arrest. ECG following ROSC is the only initial clue to the diagnosis. Hyperkalemic patients would require calcium gluconate and glucose along with Insulin. In addition to hemodialysis, to eliminate the excessive potassium load, hypokalemic patients would also need replacement therapy.

5. Sepsis: One of the common causes of cardiovascular collapse. Blood cultures are obtained, intravenous antibiotics are administered, and appropriate management is done.

What Is the Systematic Approach After Post-resuscitation Care Algorithm to Guide Treatment?

A systematic approach followed by post-resuscitation care is described as follows:

Gastrointestinal System:

• Monitor nasogastric (NG) or orogastric (OG) tube for residuals.

• A thorough abdominal examination.

• Abdominal ultrasound.

• Routine blood chemistries, including liver panels.

Respiratory System:

• Chest X-ray.

• Pulse oximetry is continuously monitored.

• Maintain adequate oxygenation at a saturation between 94 % and 99 %.

Cardiovascular System:

• Arterial blood gas (ABG) and maintained acid-base disturbances.

• Heart rate and rhythm are continuously monitored.

• Blood pressure is continuously monitored with an arterial line.

• Central venous pressure (CVP).

• Urine output.

• Chest X-ray.

Hematological System:

• Monitoring of complete blood count and coagulation panel.

• Transfuse blood (as needed):

1. Correct thrombocytopenia.

2. Fresh frozen plasma is used to replenish clotting factors.

3. Consider calcium chloride or gluconate if a massive transfusion is required.

• Correction of metabolic abnormalities after transfusion.

Neurological System:

• Monitor and treat seizures by :

1. Seizure medications.

2. Remove metabolic/toxic causes.

• Blood pressure is continuously monitored.

• Cardiac output is maintained.

• Frequent neurological examinations.

Renal System:

• Monitor urine output.

• Exceedingly high urine output could indicate a neurological or renal problem.

• Routine blood tests.

• Arterial blood gas (ABG) and correct acid/base disturbances.

• Urinalysis if needed.

• Maintaining cardiac output and renal perfusion.

• Considering the effect of medications on renal tissue (nephrotoxicity).

Conclusion:

Managing cardiac arrest patients following ROSC is difficult and requires a multidisciplinary approach. Therefore, all hospitals should establish standardized protocols for initiating and managing bundled post-ROSC care, which can eventually help in improved patient outcomes and increased survival rates. The interventions can potentially lead to an increased number of patients being discharged from the hospital alive with good neurological function.