What is the recommended post‑cardiac arrest care in the intensive‑care setting?

Post-Cardiac Arrest Care in the ICU

Immediately upon achieving return of spontaneous circulation (ROSC), implement a structured bundle of care focused on hemodynamic optimization, targeted temperature management, early coronary intervention when indicated, optimized ventilation/oxygenation, and prevention of secondary brain injury—all within the first 24 hours when cardiovascular failure causes most deaths. 1

Immediate Priorities (First 6 Hours)

Hemodynamic Stabilization

Target mean arterial pressure (MAP) ≥65 mmHg within the first 6 hours using goal-directed therapy, as cardiovascular failure accounts for most deaths in the first 3 days after cardiac arrest. 1

• Administer 1-2 L IV bolus of isotonic crystalloids (normal saline or lactated Ringer's) for hypotension (SBP <90 mmHg) 1
• Escalate to vasopressors/inotropes if fluid resuscitation inadequate 1
• Achieve central venous pressure (CVP) >12 mmHg through intravascular volume expansion 1
• Maintain central venous oxygen saturation (ScvO2) >70% within 6 hours 1
• Monitor arterial lactate and cardiac output/cardiac index to assess tissue oxygen delivery 1

Airway and Ventilation Management

Establish advanced airway with endotracheal intubation or supraglottic device immediately, confirming placement with waveform capnography. 1

• Target normocapnia: PETCO2 35-40 mmHg or PaCO2 40-45 mmHg 1
• Start at 10-12 breaths/min and titrate to target 1
• Avoid excessive ventilation, which impedes venous return and decreases cardiac output 1
• Monitor PETCO2 continuously to assess adequacy of ventilation 1

Oxygenation Management

Titrate inspired oxygen to achieve arterial oxygen saturation of 94%—avoiding both hypoxemia and hyperoxemia, as both exacerbate brain injury. 1

• Use facemask if saturation <94% for patients requiring supplemental oxygen only 1
• Avoid hyperoxemia, which worsens neurological outcomes 1

Comprehensive Monitoring Systems

Establish within minutes of ROSC: 1

• Continuous intra-arterial blood pressure monitoring 1
• Continuous cardiac telemetry and pulse oximetry 1
• Quantitative waveform capnography 1
• Core temperature monitoring 1
• Point-of-care glucose testing 1
• Serial arterial blood gases 1

Additional diagnostic monitoring: 1

• Chest radiograph to assess endotracheal tube position, heart size, and pulmonary status 1
• Echocardiography to assess post-cardiac arrest myocardial dysfunction and mechanical complications 1
• Laboratory monitoring: serum electrolytes, creatinine, complete blood count, coagulation profile 1

Targeted Temperature Management

Initiate targeted temperature management immediately for all comatose survivors, controlling body temperature to 32-34°C for 24 hours. 1

• Start temperature management as soon as possible, following local standardized treatment protocols 2
• Maintain target temperature for 24 hours 1
• Prevent hyperthermia/pyrexia, which exacerbates brain injury 1
• Provide deep sedation when neuromuscular blockade is used to prevent shivering 1
• Be aware that neuromuscular blockade can mask clinical manifestations of seizures 1

Identify and Treat Underlying Cause

Acute Coronary Syndrome Management

Obtain 12-lead ECG immediately after ROSC to identify ST-segment elevation, and perform urgent coronary angiography with prompt recanalization for patients with ST elevation or suspected cardiac cause. 2, 1

• Emergency coronary angiography improves survival to hospital discharge in patients with ST elevation after cardiac arrest 2
• Transport patients to facilities with percutaneous coronary intervention (PCI) capabilities 1
• In patients with ST elevation, 96% have a coronary artery lesion amenable to emergency treatment; in those without ST elevation, 58% have such lesions 2

Systematic Evaluation of Reversible Causes

Systematically evaluate and treat the "H's and T's": 1

• Hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia 1
• Tension pneumothorax, tamponade, toxins, thrombosis (coronary and pulmonary) 1

Prevention of Secondary Brain Injury

Post-cardiac arrest brain injury causes approximately two-thirds of deaths after out-of-hospital cardiac arrest, making neuroprotection a critical priority. 1

Avoid Factors That Exacerbate Brain Injury

• Prevent hypotension (maintain MAP ≥65 mmHg) 1
• Avoid hypercarbia, hypoxemia, and hyperoxemia 1
• Prevent pyrexia through active temperature management 1
• Maintain normoglycemia (144-180 mg/dL or 8-10 mmol/L)—both hypoglycemia and hyperglycemia worsen brain injury 1, 3
• Do not attempt tight glucose control (80-110 mg/dL) due to increased risk of hypoglycemia 3

Seizure Management

Monitor for and treat seizures with continuous EEG monitoring for all comatose patients. 1

• Continuous EEG monitoring is essential to detect seizures and epileptiform activity 1
• Neuromuscular blockade can mask clinical manifestations of seizures 1

Metabolic and Renal Management

Acute Kidney Injury Prevention

Monitor kidney function closely, including urine output and serum creatinine, as 37% of patients develop AKI after cardiac arrest. 3

• Use isotonic crystalloids rather than colloids for volume expansion 3
• Avoid starch-containing fluids 3
• Discontinue ACE inhibitors and angiotensin II receptor blockers for 48 hours post-cardiac arrest 3
• Avoid nephrotoxic medications when possible 3
• Consider early initiation of renal replacement therapy in cases with fluid overload 3

Nutritional Support

Provide appropriate nutrition support: 1

• For patients with AKI: 20-30 kcal/kg/day total energy intake 3
• Protein: 0.8-1.0 g/kg/day in noncatabolic AKI patients without dialysis; 1.0-1.5 g/kg/day in patients on renal replacement therapy 3

Neuroprognostication

Delay prognostication and use multimodal assessment to avoid self-fulfilling prophecy. 1

• Integrate clinical examination, brain imaging (MRI), and EEG findings for objective assessment 1
• Consider effects of drug accumulation during targeted temperature management on neurological assessment 1
• Serial neurological clinical examinations and brain CT or MRI are crucial for identifying structural injury 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

• Implement multidisciplinary early goal-directed therapy protocols as a bundle of care rather than single interventions 1
• A coordinated and integrated response from prehospital, emergency department, and ICU settings improves outcomes 1
• Post-cardiac arrest myocardial dysfunction peaks in the first 24 hours but typically recovers by 2-3 days 1

Common Pitfalls to Avoid

• Inadequate hemodynamic monitoring: Failure to place arterial line for continuous blood pressure monitoring 1
• Delayed coronary angiography: Missing the window for early revascularization in patients with suspected cardiac cause 2
• Hyperoxemia: Excessive oxygen administration worsens neurological outcomes 1
• Excessive ventilation: Impedes venous return and decreases cardiac output 1
• Premature neuroprognostication: Making withdrawal decisions before adequate time for neurological recovery 1
• Uncontrolled temperature: Allowing fever to develop, which exacerbates brain injury 1
• Tight glucose control: Attempting glucose targets of 80-110 mg/dL increases hypoglycemia risk 3