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ILCOR Consensus StatementPost-Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and PrognosticationA Consensus Statement From the International Liaison Committee on Resuscitation,[object Object],Circulation. 2008;118:2452-2483,[object Object]
Background,[object Object],Cardiopulmonary Resuscitation (CPR),[object Object],Resumption of Spontaneous Circulation (ROSC),[object Object],Resuscitation,[object Object],Post-CardiacArrest Syndrome (PCAS),[object Object]
Epidemiology,[object Object],The largest published in-hospital cardiac arrest database (theNRCPR) includes data from >36000 cardiac arrests.,[object Object],In-hospital mortalityrate was 67% for the 19819 adults with any documented ROSC,,[object Object],62% for the 17183 adults with ROSC >20 minutes.,[object Object]
Phases of post-cardiac arrest syndrome.,[object Object]
Pathophysiology of ,[object Object],Post–Cardiac Arrest Syndrome,[object Object]
Post-Cardiac Arrest Brain Injury,[object Object],Triage Systems in the United States,[object Object]
Post–Cardiac Arrest Myocardial Dysfunction,[object Object],Triage Systems in the United States,[object Object]
Systemic Ischemia/Reperfusion Response,[object Object],Triage Systems in the United States,[object Object]
Persistent Precipitating Pathology,[object Object],Triage Systems in the United States,[object Object]
Therapeutic Strategies,[object Object],Monitoring,[object Object],Early Hemodynamic Optimization,[object Object],Ventilation,[object Object],Circulatory Support,[object Object],Management of ACS,[object Object],Therapeutic Hypothermia,[object Object],Sedation and Neuromuscular Blockade,[object Object],Seizure Control and Prevention,[object Object],Glucose Control,[object Object],Placement of Implantable Cardioverter-Defibrillators,[object Object]
Monitoring Options,[object Object],General intensive care monitoring     ,[object Object],Arterial catheter,[object Object],Oxygen saturation by pulse oximetry     ,[object Object],Continuous ECG    ,[object Object],CVP     ,[object Object],ScvO2     ,[object Object],Temperature (bladder, esophagus)     ,[object Object],Urine output     ,[object Object],Arterial blood gases     ,[object Object],Serum lactate     ,[object Object],Blood glucose, electrolytes, CBC, and general blood sampling     ,[object Object],Chest radiograph,[object Object],More advanced hemodynamic monitoring     ,[object Object],Echocardiography     ,[object Object],Cardiac output monitoring (either noninvasive or PA catheter) ,[object Object],Cerebral monitoring     ,[object Object],EEG (on indication/continuously): early seizure detection and treatment ,[object Object],CT/MRI,[object Object]
Early Hemodynamic Optimization,[object Object],Early Goal-Directed Therapy,[object Object],CVP: 8 to 12 mm Hg, ,[object Object],MAP: 65 to 90 mm Hg, ,[object Object],ScvO2 >70%, ,[object Object],Hematocrit >30% or hemoglobin >8 g/dL, ,[object Object],lactate <2mmol/L, ,[object Object],urine output >0.5 mL · kg–1 · h–1, ,[object Object],oxygen deliveryindex >600 mL · min–1 · m–2,[object Object]
Post Cardiac Arrest Syndrome
VentilationSurviving Sepsis CampaignRecommends:,[object Object]
Circulatory Support,[object Object],Dysrhythmias can be treated by maintenance of normal electrolyteconcentrations, use of standard drug and electrical therapies.,[object Object],The first-line intervention for hypotension is to optimize right-heart filling pressures by use of IV fluids. In 1 study,3.5 to 6.5 L of IV crystalloid was required in thefirst 24 hours after ROSC after OHCAto maintain CVP in the range of 8 to 13 mmHg.,[object Object]
Circulatory Support,[object Object],Inotropes and vasopressors should be considered if hemodynamicgoals are not achieved despite optimized preload.,[object Object],Early echocardiography willenable the extent of myocardial dysfunction to be quantifiedand may guide therapy. ,[object Object],Additionalcardiac support: intra-aorticballoon pump (IABP), percutaneous cardiopulmonary bypass, extracorporeal membraneoxygenation (ECMO), transthoracic ventricular assist devices.,[object Object]
Management of ACS,[object Object],Patients resuscitated from cardiac arrest who have ST-elevation myocardial infarctionshould undergo immediate coronary angiography, with subsequentPCI if indicated.,[object Object],It is appropriate toconsider immediate coronary angiography in all post–cardiacarrest patients in whom ACS is suspected.,[object Object]
Therapeutic Hypothermia,[object Object],Unconscious adult patientswith ROSC after out-of-hospital VF cardiacarrest should be cooled to 32°C to 34°C for at least12 to 24 hours.,[object Object],Rapid IV infusion of ice-cold 0.9% salineor Ringer’s lactate (30 mL/kg) is a simple, effectivemethod for initiating cooling.,[object Object],Slow rewarming: 0.25°C to 0.5°C per hour.,[object Object],If therapeutic hypothermia is not undertaken, pyrexia duringthe first 72 hours after cardiac arrest should be treated aggressivelywith antipyretics or active cooling.,[object Object]
Sedation and Neuromuscular Blockade,[object Object],Critically ill post–cardiac arrest patientswill require sedation for mechanical ventilation and therapeutichypothermia. ,[object Object],Adequate sedation is particularly important for prevention ofshivering during induction of therapeutic hypothermia, maintenance,and rewarming.,[object Object]
Seizure Control and Prevention,[object Object],Prolonged seizures may cause cerebral injury andshould be treated promptly and effectively with benzodiazepines,phenytoin, sodium valproate, propofol, or a barbiturate.,[object Object],Clonazepam is the drug of choice for the treatmentof myoclonus. ,[object Object]
Glucose Control,[object Object],Tight control blood glucose (80 to 110mg/dL) with insulin reduced hospital mortality rates in criticallyill adults.,[object Object]
Placement of Implantable Cardioverter-Defibrillators,[object Object],In survivors with good neurological recovery, insertion of anICD is indicated if subsequentcardiac arrests cannot be reliably prevented by other treatments(such as pacemaker for AV block, transcatheterablation of a single ectopic pathway, or valve replacement forcritical aortic stenosis).,[object Object]

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