post resuscitation syndrome - andrianto, md, fiha.pdf
TRANSCRIPT
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Post Resuscitation Syndrome“Restart the heart and keep it restarted”
AndriantoRuthvi Adriana
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CARDIOVASCULAR EMERGENCIES COURSEBumi 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
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Patient is ROSC
What’s happen?
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Post Resuscitation Syndrome
To minimizeBrain injury
To correctMyocardial dysfunction
To manageSystemic ischemia -
reperfusion response
To detect and treatPersistent precipitating
pathology
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Not only
Return of Spontaneous Circulation (ROSC)
but
Return to Pre Arrest Status
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Post Resuscitation Syndrome
To minimizebrain injury
To correctmyocardial dysfunction
To managesystemic ischemia -
reperfusion response
To detect and treatpersistent precipitating
pathology
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
![Page 8: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/8.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Our approach should be:
Comprehensive
Structured
Multidisciplinary system of care
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
ManagementROSC
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.
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Patient comatose
• Focused history and physical examination• Laboratory & imaging examination
• Initiate cardiopulmonary and metabolic stabilization•Treat precipitating cause
Multidisciplinary System of Care
Patient non comatose
Therapeutichypothermia
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Ventilation
• Maintain good airway
• Adequate oxygenation and ventilation
• Intubation if needed
• Avoid hypo-hyperventilation
• Reduce FIO2 as tolerated → SPO2 ≥94%
• PaCO2 40–45 mm hg
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 14: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/14.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 15: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/15.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
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
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 16: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/16.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 17: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/17.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Metabolic• Frequent electrolyte monitoring
• Adequate repletion of K, Mg to keep K › 3.5 mEq/L
• Treat hypo-hyperkalemia
• Avoid hypo/hyperglycaemia (target glucose 144–180 mg/dL)
• Monitor urine output
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 18: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/18.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 19: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/19.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Neurological
Baseline neurological examination
Imaging of brain to assess for ischemia / haemorrhage
if clinically indicated
EEG to assess subclinical seizures
Therapeutic hypothermia
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
![Page 20: Post Resuscitation Syndrome - Andrianto, MD, FIHA.pdf](https://reader031.vdocuments.mx/reader031/viewer/2022011720/577c83551a28abe054b4980f/html5/thumbnails/20.jpg)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Benson et al,Anesth Analg 1959; 38: 423-8.
Comatose survivors
Asystole or VF
31-32°C
Cooling until neurologic recovery(3 hours to 8 days)
Water-filled blanket
0102030405060
Favorable neurologicrecovery
%
Hypothermia (n=12)
Normothermia (n=7)
The Use of HypothermiaAfter Cardiac Arrest
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Hypothermia
Normothermia
P 0.02
Mild therapeutic hypothermia to improve the neurologic outcome after cardiacarrest. N Engl J Med. 2002;346:549-556.
Mild therapeutic hypothermiato improve the neurologic outcome
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Cooling Technique
Cooling blankets
Ice / cold liquid packing
Ice / cold liquid gastric lavage
IV cooling catheter
Cooling mist
Other method
0% 10% 20% 30% 40% 50%
Cooling technique Percentage of respondents
50%
15%
13%
2%
2%
17%
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Coolong Blankets
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
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 12-
24h Stop all sedation when normal body temperature is
achieved
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Monitoring:
Seizure, shivering
Aritmia & unstable hemodinamic → rewarmed
Electrolyte imbalance (Mg,K,P,Ca,Na ↓)
Temperature check, skin care
Bleeding , dehydration, infection
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
The 2005 AHA guidelines:
Comatose, ventricular fibrillation (VF) (class IIA)
Comatose, other rhythms (class IIB)
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Prognostication
Pre-Arrest
o Age
o Comorbidities
Arrest
o Collapse to CPR time
o Prolonged CPR
o Initial Rhythm
o CPR quality
Post - arrest
o Clinical examination
o EEG
o Somatosensory
evoked potential
o Neurological
biochemical marker
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Summary
The rate of ROSC continues to increase and proper post-
resuscitation 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 neuro-
protective after return of spontaneous circulation
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Thank You
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Outcomes of Therapeutic Hypothermia
Alive at hospital discharge - favorable neurological recovery
Alive at 6 months - favorable neurological recovery
Hypothermia NormothermiaHACA Study Group 72/136 (53%) 50/137 (36%)
Bernard 21/43 (49%) 9/34 (26%)
Hachimi-Idrissi 4/16 (25%) 1/17 (6%)
Hypothermia NormothermiaHACA Study Group 72/136 (52%) 50/137 (36%)
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015