What are the recommendations for post-resuscitation care?

Post-Resuscitation Care Recommendations

Post-resuscitation care should focus on four critical pillars: urgent coronary intervention for cardiac causes, targeted temperature management at 32-36°C, multimodal delayed prognostication, and systematic rehabilitation with cognitive screening. 1

Immediate Post-ROSC Management

Hemodynamic Optimization

• Target mean arterial pressure ≥65 mmHg to maintain adequate cerebral and systemic perfusion 2
• Maintain oxygen saturation 92-98% to avoid both hypoxemia and hyperoxemia 2
• Monitor urine output targeting 1 ml/kg/h and decreasing plasma lactate as markers of adequate perfusion 1
• Accept bradycardia ≤40 bpm if blood pressure, lactate, central venous oxygen saturation, and urine output remain adequate—this is associated with good outcomes during temperature management 1
• Use arterial line for continuous blood pressure monitoring; consider cardiac output monitoring in hemodynamically unstable patients 1

Airway and Ventilation

• Secure airway with endotracheal tube or supraglottic device, confirmed by waveform capnography 2
• Provide 1 breath every 6 seconds (10 breaths/min) with continuous compressions once advanced airway placed 2
• Target tidal volume 10 ml/kg with respiratory rate 12-15/min to achieve 100% oxygen initially 1
• Perform serial blood gas analysis; use pulse oximetry for continuous monitoring 1

Coronary Intervention

Perform urgent coronary angiography and percutaneous coronary intervention for all out-of-hospital cardiac arrest patients with likely cardiac cause, regardless of initial ECG findings. 1

• This represents the most significant change in post-resuscitation care and takes priority over other interventions 1
• Transfer directly to cardiac catheterization laboratory before ICU admission if cardiac etiology suspected 1
• In absence of clear cardiac cause, perform brain and chest CT scan to identify neurological or respiratory causes 1
• If trauma or hemorrhage associated with arrest, obtain whole body CT scan 1

Targeted Temperature Management (TTM)

Initiate TTM as quickly as possible, targeting 32-36°C (not just 32-34°C as previously recommended) for at least 24 hours. 1

Temperature Protocol

• Begin cooling immediately upon ROSC using standardized local treatment plan 1
• Maintain target temperature for minimum 24 hours 3
• Rewarm slowly at ≤0.5°C per hour to prevent complications 3
• Continue controlled sedation and mechanical ventilation throughout TTM period 3

Monitoring During TTM

• Expect physiological bradycardia during hypothermia—this is protective, not harmful 1
• Monitor for hypokalemia and hypomagnesemia, which occur frequently 3
• Recognize that hypothermia increases urine output and impairs lactate clearance 1
• Moderately increased risk of infection and bleeding 3

Prognostication Strategy

Use multimodal prognostication only after allowing sufficient time for neurological recovery and sedative clearance—avoid early withdrawal of life support based on clinical assessment alone. 1

Timing Considerations

• Cardiovascular failure causes most deaths in first 3 days post-ROSC 4
• Brain injury becomes predominant cause of death after day 3 4
• Self-fulfilling prophecy poses real threat to early prognostication 3
• Delayed prognostication is now considered key element of post-resuscitation care 3

Awakening Patterns

• 15-46% of out-of-hospital cardiac arrest patients awaken rapidly and may not require prolonged ICU stay 1, 4
• Among those remaining comatose, 94% who awaken do so within 3 days, remaining 6% within 10 days 1
• Even late awakening patients can achieve good neurological outcome 1

Electrolyte and Metabolic Management

• Expect initial hyperkalaemia immediately post-arrest, followed by hypokalaemia from catecholamine release and acidosis correction 1
• Maintain electrolyte concentrations at low-normal range in comatose patients 1
• Measure blood glucose urgently; infuse glucose only for documented hypoglycemia 1
• Avoid routine steroid administration—insufficient evidence for benefit after out-of-hospital cardiac arrest 1

Seizure Management

• Control seizures with anticonvulsants (diazepam, phenytoin, barbiturates) as they occur 1
• Early seizures do not always indicate irreversible neuronal damage 1

Rehabilitation and Follow-Up

Systematically organize follow-up care including mandatory screening for cognitive and emotional impairments, with provision of structured information. 1

Cognitive Impairments

• Long-term cognitive impairments present in 50% of survivors, most commonly affecting memory, attention, and executive function 1
• These impairments are often mild but not detected by standard scales (CPC, MMSE) 1
• Screen using patient and caregiver interviews about memory, attention, and planning problems 1
• Administer Montreal Cognitive Assessment (MoCA) or Checklist Cognition and Emotion 1
• Refer to neuropsychologist when impairments identified 1

Emotional Problems

• Depression occurs in 14-45%, anxiety in 13-61%, posttraumatic stress in 19-27% of survivors 1
• Fatigue affects 56% even years after arrest 1
• Partners and caregivers experience high burden and emotional problems including posttraumatic stress 1

Effective Interventions

• Nursing interventions focusing on physiological relaxation, self-management, coping strategies, and health education reduce cardiovascular mortality and depression 1
• Telephone-based interventions with 24/7 nurse access improve physical symptoms, anxiety, self-confidence, and disease knowledge 1
• Early screening programs with 1-2 consultations, information booklets, and referral pathways improve emotional state, anxiety, quality of life, and return to work 1

ICU Admission and Resource Planning

• All patients achieving ROSC require transfer to high-care area (ICU, emergency department with critical care capabilities, or cardiac catheterization laboratory) 4
• Expected ICU length of stay averages 5-10 days for survivors 4
• 28-40% may die or have care withdrawn within first 1-3 days 4
• ICUs admitting >50 post-cardiac arrest patients annually demonstrate better survival than those admitting <20 cases, supporting regionalization to specialized cardiac arrest centers 4, 3, 5

Critical Pitfalls to Avoid

• Do not delay coronary angiography waiting for neurological assessment in suspected cardiac arrest 1
• Do not treat bradycardia <40 bpm during TTM if perfusion parameters adequate 1
• Do not prognosticate early based on clinical assessment alone—wait for sedative clearance and use multimodal approach 1, 3
• Do not assume good CPC score means no cognitive impairment—specific screening required 1
• Do not discharge without rehabilitation plan—cognitive and emotional problems are common and treatable 1