Post-resuscitation care

Regardless of the cause of cardiac arrest, the hypoxia, ischaemia and reperfusion that occur during and after the resuscitation phase result in damage to multiple organ systems.This condition, called post-cardiac arrest syndrome, comprises four major components: (a) Persistent precipitating pathology: the precipitating aetiology that leads to cardiac arrest needs to be rapidly identifi ed and addressed.The most common pathology is coronary thrombus, which causes myocardial infarction.Other noncoronary causes that can lead to cardiac arrest include hypoxia, pulmonary embolism (PE) and sepsis.(b) Anoxic brain injury: the reperfusion that occurs after a period of cerebral hypoxia results in the formation of free radicals and activation of cell-death signalling pathways causing disturbance of cerebral microvascular homeostasis.This injury can continue for hours to days and is aggravated by additional insults such as fever, poor glucose control and hyperoxia.The symptoms of anoxic brain injury include coma, seizures, myoclonus, various degrees of neurocognitive dysfunction and brain death.(c) Post-cardiac arrest myocardial dysfunction: there is hypokinesia of the cardiac muscles associated with a significant drop in left ventricular ejection fraction, especially during the fi rst 24-48 hours after ROSC.It occurs despite preserved coronary blood fl ow.This manifests as tachycardia, hypotension, poor cardiac output and elevated left ventricular end-diastolic pressure.(d) Systemic ischaemia/reperfusion response: whole-body hypoxia/ischaemia followed by post-ROSC reperfusion results in systemic infl ammation, endothelial activation, and activation of the immunologic and coagulation pathways.This resembles the pathophysiology occurring during severe sepsis and increases the risk of multiple organ dysfunction syndrome.Clinical manifestations include fever and altered oxygen consumption, as well as increased susceptibility to infection.Post-resuscitation care is an evolving science that requires a well-coordinated multidisciplinary effort with participation of physicians from the disciplines of emergency medicine, critical and intensive care, nursing, cardiology and anaesthesiology, at the very least.There is a need to identify approaches and optimise workfl ow for the integration of post-ROSC care as a standard of care in treating cardiac arrest patients who attain ROSC.This can be achieved by determining how the various interventions needed in post-resuscitation care can be bundled into a care regimen and implemented in most clinical care areas.In this article, the National Resuscitation Council, Singapore, has evaluated the current research in this fi eld and produced the guidelines that can be further adopted in our clinical practice and updated with research in our local setting and environment. SCOPE OF POST-ROSC CARECardiac arrest is multifactorial and can severely affect multiple organ systems regardless of cause, hypoxaemia, ischaemic injuries and reperfusion injuries.(1) Post-resuscitation care must be tailored Post-resuscitation care Post-resuscitation care