Post Resuscitation Care

Post CPA care and monitoring is extremely important to increase chances of sustained ROSC and survival. Coordinate medical evacuation to a higher echelon of care.

Multiorgan failure, cardiogenic shock, anoxic brain injury and underlying causes of death may all contribute to subsequent arrest in the post-resuscitation period, typically within 24 hours.

Prophylactic anticonvulsant therapy may be considered in the post-arrest period but convincing evidence of benefit in human or veterinary medicine is lacking.

POST ARREST MONITORING

Following ROSC, ECG, blood pressure and pulse oximetry (SpO2) monitoring should continue. ETCO2 should be monitored until extubation.

Laboratory assessments, if available, should include acid-base, lactate, blood glucose and electrolyte monitoring every 4-6 hours, a complete blood count (CBC) and biochemistry panel every 12-24 hours, and baseline coagulation monitoring.

RESPIRATORY OPTIMIZATION

If not spontaneously breathing, continue positive pressure ventilation (with oxygen) until oxygenation (SpO2) reaches 94 – 98% and ETCO2 equals 32 – 43 mmHg.5 Avoid hyperoxemia or hypercapnia.

If spontaneously breathing, but normocapnia or normoxemia cannot be maintained, consider re-intubation and mechanical ventilation.

HEMODYNAMIC OPTIMIZATION

The following end points should be used as guidelines for post-arrest care:5,10

- Systolic blood pressure: 100 – 200 mmHg
- Mean arterial pressure: 80 – 120 mmHg
- Central venous O2 saturation ≥ 70%
- Lactate < 2.5 mmol/L
- Packed cell volume (PCV) > 25%

If goals are not achieved and the patient is hypovolemic, administer incremental isotonic fluid boluses (20 mL/kg isotonic crystalloid). Administer blood products if hemorrhage or pre-existing anemia contributed to CPA.

If goals are not achieved and hypovolemia is NOT present, vasodilation may be the cause and vasopressors may be required, which require critical care capability. Options include:

- Norepinephrine 0.05 – 2 mcg/kg/min IV
- Dopamine 2 – 10 mcg/kg/min IV
- Epinephrine 0.05 – 1 mcg/kg/min IV
- Routine use of corticosteroids is not recommended as part of post-arrest care.

If neither hypovolemia nor vasodilatory shock is likely, focused cardiac ultrasound should be used (if feasible or available) to determine if reduced systolic function is the cause of hemodynamic instability. If so, a positive inotrope should be administered.

- Dobutamine 5 – 20 mcg/kg min IV (start with low dose and titrate upward).

Control pathologic ventricular arrhythmias with lidocaine (2 mg/kg IV bolus to break of slow the rhythm, up to 8 mg/kg) followed by a constant rate infusion (50-75 mcg/kg/min).

NEUROPROTECTION

Control seizures that develop with diazepam (0.5 mg/kg, IV, IO or IN) or midazolam (0.3 mg/kg, IV, IO or IN), repeated every 15-30 minutes if necessary. If available, give levetiracetam 60 mg/kg IV and 20 mg/kg every 8 hours thereafter, or phenobarbital (4 mg/kg IV every 1-4 hours to load, up to 16 mg/kg) and 2.5 mg/kg IV every 12 hours thereafter.

If an MWD is showing signs of cerebral edema (abnormal mentation, cranial nerve deficits, or abnormal posture), administer mannitol (0.5 gram/kg, IV, over 15-20 minutes) or 7.5% hypertonic saline 2-4 mL/kg IV. Avoid hypoventilation, avoid jugular vein compression and maintain normoxemia and normotension.

Do not attempt tight control of blood glucose with insulin. Supplement IV fluids if hypoglycemia is present (2.5 - 5% dextrose CRI, with close monitoring to maintain glucose between 60 – 150 mg/dL) but avoid hyperglycemia.

While targeted temperature management, formerly known as therapeutic hypothermia, can improve neurologic outcomes and survival in dogs, this is not practical in the deployed setting due to the need for mechanical ventilation and advanced critical care. Tolerate mild hypothermia (> 92°F) if it develops and avoid rapid rewarming. Slow rewarming at a rate of < 1.8°F per hour is recommended.