Post Resuscitation Management


Article Author:
Roy Vega


Article Editor:
Ofek Hai


Editors In Chief:
Laurie Graham
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/18/2019 2:34:49 PM

Introduction

Mortality rates after pediatric cardiac arrest remain high after initial resuscitation and a return of spontaneous circulation. Several factors must be addressed to optimize survival and to prevent subsequent deterioration and/or organ dysfunction and neurologic sequelae. [1][2] 

Priorities post-resuscitation include ongoing assessment of the resuscitation and stabilization process, determining and managing the etiology of the arrest, neuroprotection to maintain and or minimize brain injury, and preventing decompensation while managing the patient in the emergency department setting, and/or while transporting to a high level of care (pediatric intensive care unit).

After a return of spontaneous circulation further stabilization and diagnostic assessments are required.

A post-arrest reevaluation includes assessing the adequacy of pulses, both central and peripheral, capillary refill, blood pressure, adequacy of oxygenation and ventilation. This should include continuous cardiac monitoring including pulse oximetry and end-tidal carbon dioxide (CO2) measurements.

Perfusion is often compromised post-arrest, and additional fluid boluses and inotropic agents may be required. Dopamine is often helpful to help stabilize blood pressure and improve renal flow. Dobutamine is a good agent for patients in need of a chronotropic agent and does not increase afterload.

Post-arrest patients may be hypotensive. Continuous epinephrine infusions are preferred for several reasons. Epinephrine causes peripheral vasoconstriction which helps to improve blood pressure. Epinephrine is also a potent inotropic and chronotropic agent.

If the etiology of the cardiac arrest was an arrhythmia, then loading the patient with appropriate antiarrhythmic agents such as lidocaine or amiodarone may be needed. Constant cardiac monitoring is needed to evaluate for the recurrence of worrisome rhythms. Addressing factors that may lead to arrhythmia must also be addressed for example hypoxia, acidosis, hypo/hyperkalemia.

Function

Post Resuscitation care also includes obtaining laboratories studies or repeating studies such as arterial blood gases, or lactate levels if sepsis is suspected. [3][4] 

  • Chest radiographs are important in assessing endotracheal tube placement, the presence of infiltrates, effusions, cardiomegaly, or signs of trauma.
  • Disposition should be focused on early. Pediatric intensive care consultation, bed availability, and/or the need for transferring to another facility with a higher level of care may be required.
  • Documentation, the reviewing of imaging, and laboratory studies are an integral part of post-resuscitation care.

Goal-directed therapy has emerged as an important aspect of post-resuscitation care. This includes ensuring that the patient is euthermic and normoglycemic and that electrolytes, including calcium and phosphorus, are in proper balance. Data suggest that fever after pediatric cardiac arrest is common and is associated with poor outcomes. The American Heart Association (AHA) guidelines also recommend temperature control during the post-stabilization phase post-arrest.

Social services and clergy can be helpful when a return of spontaneous circulation has not been achieved, and the patient has died. A dedicated provider should keep the family updated if they are not present during the resuscitation.

Issues of Concern

The local medical examiner, organ donation services, and in some cases child protective services may be needed. Regardless of the result of the resuscitation, post-resuscitation debriefing of the code team should occur.

The American Heart Association (AHA) also emphasizes the role and importance of debriefing, post-resuscitation. Debriefing sessions following cardiac arrest typically include the following:

  1. What were the team’s initial assessment and management?
  2. Were roles clearly defined?
  3. Was a team leader clearly defined?
  4. Were there any communication issues?
  5. Was closed-loop communication employed?
  6. Were there any issues that team members were concerned about?
  7. Were there any areas in need of improvement?
  8. It is also important to assess the emotional and psychological impact of the event, especially when it comes to providers in-training (nursing or medical students, interns). 

Debriefing is a critical conversation which should be blame free. It serves to clarify perspectives and assumptions, both subjectively and objectively, by the parties involved. It also fosters critical thinking and promotes self-reflection.

Clinical Significance

Predictive Factors After Cardiac Arrest [2][5][6][7][8]

Several post-ROSC factors may be predictive of survival and neurologic outcome after pediatric cardiac arrest. These include pupillary responses, the presence of hypotension, and serum lactate.

Sepsis and the post-arrest period share similar features. Both exhibit elevated serologic markers, endothelial dysfunction, and microcirculatory hypoperfusion. As with sepsis, important early goals in the post-arrest period include normalizing blood pressure with fluid boluses and pressor support as needed, maintaining adequate oxygenation and ventilation, and achieving glycemic control. The main cause of death after the return of spontaneous circulation in children is a brain injury. Protecting the brain against secondary injury by the management of seizures, obtaining glycemic control, and considering therapeutic hypothermia. A recent article in the New England Journal of Medicine by Moler et al., explains therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a favorable functional outcome at one year.

According to the AHA, there is currently insufficient evidence to make a recommendation on the use of therapeutic hypothermia in children resuscitated from cardiac arrest.

After a return of spontaneous circulation children may experience the post-cardiac arrest syndrome.

This is a unique and complex combination of pathophysiological processes, which include (1) post-cardiac arrest brain injury, (2) post–cardiac arrest myocardial dysfunction, and (3) systemic ischemia/reperfusion response. A possible fourth component is the unresolved pathological process that caused the cardiac arrest.

The value of end-tidal carbon dioxide (ETCO2) monitoring has emerged as more than just an adjunct to endotracheal tube placement and assessment of ventilation. Continuous end-tidal CO2 monitoring has an important role in a cardiac arrest. A return of spontaneous circulation may be detected sooner with ETCO2 monitoring compared to pulse checks. Ongoing measurements can help identify dislodgement of the endotracheal tube or hypoventilation.

During the post-stabilization phase, sedation and muscle relaxation should be considered. Sedation can be provided by bolus therapy or continuous infusion. Agents can include midazolam, ketamine or propofol. Due to the short half-life of propofol, it is best reserved as a continuous infusion. If there are concerns about sepsis propofol should be avoided due to the risk of propofol infusion syndrome. The propofol infusion syndrome is a life-threatening condition characterized by acute refractory bradycardia progressing to asystole. It also includes one or more of the following features: metabolic acidosis, rhabdomyolysis, hyperlipidemia, and/or enlarged or fatty liver.

Muscle relaxation (paralysis), can also be achieved by bolus therapy or continuous infusion. Agents such as rocuronium or vecuronium are non-depolarizing muscle relaxants commonly used in pediatrics. Most hospitals have standardized titration tables that can assist with proper weight-based dosing. However, these agents should be kept to a minimum if possible as they preclude thorough neurological assessments that are in the early period (12 to 72 hours) after the return of spontaneous circulation.

Enhancing Healthcare Team Outcomes

Post-resuscitation of patients is usually done in the ICU setting with a multidisciplinary team that includes a neurologist, intensivist, primary care provider, ICU nurses, social worker, and an ethics team. Because many patients do not survive and have a poor prognosis, open communication with the family is necessary. An ethics team should be involved early on so that the family is aware of the options of care. Even those who survive are often left with anoxic brain damage and face numerous problems with daily living. Nurses staff should update the family regularly on patient status and permit them to see the patient more frequently, if there is no hope for salvage.[9]


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Post Resuscitation Management - Questions

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Which of the following laboratory tests are considered end points to fluid resuscitation in the pediatric and adult populations?



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In which of the following cases should targeted temperature management (TTM) be initiated?



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Which of the following is not a priority post-resuscitation?



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Which is included in managing hypotension in the post-resuscitation phase?



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Which of the following is not a question to be reviewed during debriefing sessions?



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Which factors that are predictive of survival and neurologic outcome after pediatric cardiac arrest?



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Which of the following is not a factor that can be encountered in the post-cardiac arrest syndrome following a return of spontaneous circulation in children?



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Which is true of the values of continuous end-tidal carbon dioxide monitoring?



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Post Resuscitation Management - References

References

Outcome prediction by motor and pupillary responses in children treated with therapeutic hypothermia after cardiac arrest., Abend NS,Topjian AA,Kessler SK,Gutierrez-Colina AM,Berg RA,Nadkarni V,Dlugos DJ,Clancy RR,Ichord RN,, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2012 Jan     [PubMed]
Serum biomarkers of brain injury to classify outcome after pediatric cardiac arrest*., Fink EL,Berger RP,Clark RS,Watson RS,Angus DC,Richichi R,Panigrahy A,Callaway CW,Bell MJ,Kochanek PM,, Critical care medicine, 2014 Mar     [PubMed]
Early lactate elevations following resuscitation from pediatric cardiac arrest are associated with increased mortality*., Topjian AA,Clark AE,Casper TC,Berger JT,Schleien CL,Dean JM,Moler FW,, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2013 Oct     [PubMed]
Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest., Nagao K,Nonogi H,Yonemoto N,Gaieski DF,Ito N,Takayama M,Shirai S,Furuya S,Tani S,Kimura T,Saku K,, Circulation, 2016 Apr 5     [PubMed]
The Utility of Therapeutic Hypothermia for Post-Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm., Perman SM,Grossestreuer AV,Wiebe DJ,Carr BG,Abella BS,Gaieski DF,, Circulation, 2015 Dec 1     [PubMed]
Funada A,Goto Y,Tada H,Teramoto R,Shimojima M,Hayashi K,Kawashiri MA,Yamagishi M, Duration of cardiopulmonary resuscitation in patients without prehospital return of spontaneous circulation after out-of-hospital cardiac arrest: Results from a severity stratification analysis. Resuscitation. 2018 Mar;     [PubMed]
Fink EL,Clark RSB,Berger RP,Fabio A,Angus DC,Watson RS,Gianakas JJ,Panigrahy A,Callaway CW,Bell MJ,Kochanek PM, 24 vs. 72 hours of hypothermia for pediatric cardiac arrest: A pilot, randomized controlled trial. Resuscitation. 2018 May;     [PubMed]
Scholefield BR,Silverstein FS,Telford R,Holubkov R,Slomine BS,Meert KL,Christensen JR,Nadkarni VM,Dean JM,Moler FW, Therapeutic hypothermia after paediatric cardiac arrest: Pooled randomized controlled trials. Resuscitation. 2018 Dec;     [PubMed]
Chan HY,Ng JS,Chan KS,Ko PS,Leung DY,Chan CW,Chan LN,Lee IF,Lee DT, Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial. International journal of nursing studies. 2018 Nov;     [PubMed]

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