What are the key components of post cardiac arrest care in the ICU?

Post-Cardiac Arrest Care in the ICU

Implement a comprehensive, structured, multidisciplinary system of care that includes immediate hemodynamic optimization, targeted temperature management, early coronary angiography when indicated, optimized ventilation/oxygenation, and prevention of secondary brain injury—all within the first 24 hours when most deaths occur. 1, 2

Immediate Priorities Upon ICU Admission

Hemodynamic Optimization (First 6 Hours)

Target mean arterial pressure (MAP) ≥65 mmHg using goal-directed therapy within the first 6 hours. 2

• Administer 1-2 L IV bolus of normal saline or lactated Ringer's to treat hypotension (SBP <90 mmHg) 1
• Target central venous pressure (CVP) >12 mmHg through intravascular volume expansion 2
• Maintain central venous oxygen saturation (ScvO2) >70% within 6 hours 2
• Use vasopressors/inotropes if fluid resuscitation inadequate: 1
  • Epinephrine infusion: 0.1-0.5 mcg/kg/min (7-35 mcg/min in 70-kg adult)
  • Dopamine infusion: 5-10 mcg/kg/min
  • Norepinephrine infusion: 7-35 mcg/min in 70-kg adult

This aggressive early hemodynamic optimization is critical because cardiovascular failure accounts for most deaths in the first 3 days. 2

Airway and Ventilation Management

Establish advanced airway with endotracheal intubation or supraglottic device and confirm placement using waveform capnography. 1, 2

Target normocapnia with PETCO2 of 35-40 mmHg or PaCO2 of 40-45 mmHg. 2

• Start at 10-12 breaths/min and titrate to target 1
• Avoid excessive ventilation—do not hyperventilate as this impedes venous return and decreases cardiac output 1
• Monitor PETCO2 continuously to assess CPR quality and detect ROSC 1

Oxygenation Management

Titrate inspired oxygen to achieve arterial oxygen saturation of 94%—avoiding both hypoxemia and hyperoxemia. 2

• Use facemask if saturation <94% for patients requiring supplemental oxygen only 2
• Titrate FiO2 to minimum necessary to achieve SpO2 ≥94% 1
• Both hypoxemia and hyperoxemia exacerbate brain injury 2

Targeted Temperature Management (TTM)

Initiate targeted temperature management immediately for all comatose survivors, controlling body temperature to 32-36°C for at least 24 hours. 1, 2, 3

• Begin cooling as quickly as possible after ROSC 1, 4
• Maintain target temperature for 24 hours 2, 4
• Prevent fever/hyperthermia (temperature >37.7°C) for at least 72 hours as it exacerbates brain injury 2, 3
• Rewarm slowly at ≤0.5°C per hour 4
• May use 4°C IV fluids if inducing hypothermia 1

Important caveat: Do not use prehospital cooling with rapid infusion of large volumes of cold IV fluids immediately after ROSC 3. TTM is linked to increased risk of infection, bleeding, hypokalemia, and hypomagnesemia—monitor and correct electrolytes frequently 4.

Sedation and Shivering Management

Provide deep sedation when neuromuscular blockade is used to prevent shivering during TTM, ensuring the patient cannot experience awareness. 1

• Sedation goals differ from general ICU patients—these patients are already unconscious from brain injury 1
• Be aware that neuromuscular blockade can mask clinical manifestations of seizures 1
• Avoid excessively deep or prolonged sedation as it delays neuroprognostication and increases complications (delirium, infections, prolonged ventilation, longer ICU stay) 1
• Drug metabolism and clearance are altered considerably during TTM, which can delay accurate neuroprognostication 1

Identify and Treat Underlying Cause

Acute Coronary Syndrome Management

Perform early coronary angiography for patients with suspected cardiac cause and ST-segment elevation on ECG. 2

• Transport patients to facilities with percutaneous coronary intervention (PCI) capabilities 2
• Immediate coronary reperfusion when indicated is essential for restoration of coronary blood flow 1, 4

Address Reversible Causes ("H's and T's")

Systematically evaluate and treat: 1

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis)
• Hypo-/hyperkalemia, Hypothermia
• Tension pneumothorax, Tamponade (cardiac)
• Toxins, Thrombosis (pulmonary), Thrombosis (coronary)

Prevent Secondary Neurological Injury

Avoid all factors that exacerbate brain injury: 2

• Hypotension (maintain MAP ≥65 mmHg)
• Hypercarbia and hypocarbia (target PaCO2 40-45 mmHg)
• Hypoxemia and hyperoxemia (target SpO2 94%)
• Pyrexia/fever (maintain temperature <37.7°C for ≥72 hours)
• Hypoglycemia and hyperglycemia (maintain normoglycemia)
• Monitor for and treat seizures aggressively

Metabolic Management

Maintain normoglycemia as both hypoglycemia and hyperglycemia worsen brain injury. 2

• Target moderate glycemic control (144-180 mg/dL or 8-10 mmol/L) 5
• Do not attempt tight glucose control (80-110 mg/dL) due to increased risk of hypoglycemia and potential for worse outcomes 5

Acute Kidney Injury Prevention and Management

Monitor kidney function closely (urine output and serum creatinine) as patients are at high risk for AKI. 5

• Use isotonic crystalloids rather than colloids for volume expansion 5
• Avoid starch-containing fluids 5
• Discontinue ACE inhibitors and ARBs for 48 hours post-arrest 5
• Adjust medication dosages for impaired kidney function 5
• Consider early renal replacement therapy, particularly with fluid overload 5

Neuroprognostication

Delay prognostication and use multimodal assessment to avoid self-fulfilling prophecy. 4

• Clinical assessment alone is insufficient for early prognostication 4
• Drug accumulation during TTM delays accurate neurological assessment 1
• Objectively assess prognosis for recovery using structured protocols 1

Systems of Care Approach

Transport patients to comprehensive post-cardiac arrest treatment centers with capabilities for acute coronary interventions, neurological care, and goal-directed critical care. 1, 2

• Positive associations exist between survival and number of cardiac arrest cases treated at individual hospitals 1
• Implement multidisciplinary early goal-directed therapy protocols as a bundle of care rather than single interventions 1, 2
• Most deaths occur during the first 24 hours after cardiac arrest—making this initial period critical 1

Key Pitfalls to Avoid

• Do not hyperventilate—this decreases cardiac output and worsens outcomes 1
• Do not use excessive oxygen—hyperoxemia causes oxygen toxicity and worsens brain injury 2
• Do not allow fever—even mild hyperthermia exacerbates neurological damage 2, 3
• Do not prognosticate too early—wait until sedation/hypothermia effects have cleared 1, 4
• Do not use light sedation during TTM with NMB—this risks patient awareness 1