5 - Postcardiac arrest care

Abstract

The majority of dogs or cats with return of spontaneous circulation (ROSC) are euthanized or die before hospital discharge. Thus, the optimization of post-cardiac arrest (PCA) care has the potential to save many lives. While general critical care principles are sufficient to guide much of the clinical approach to these animals, some treatment considerations are unique to the PCA dog or cat; specifically, the systemic response to ischemia and reperfusion, anoxic brain injury, and postresuscitation myocardial dysfunction. Persistent precipitating pathologic conditions define PCA care measures needed for each individual patient. Immediately after ROSC, treatment focuses on the prevention of rearrest by ensuring optimal ventilation, oxygenation, and tissue perfusion, as well as identifying and correcting reversible causes of cardiopulmonary arrest. Hypoxemia and hyperoxemia early after ROSC should be avoided by controlled reoxygenation with a target SaO2/SpO2 of 94% to 98% or a PaO2 of 80 to 100 mm Hg. Hemodynamic optimization measures after ROSC include administration of intravenous fluids, pressors, inotropes, and blood products to reach a mean arterial pressure of 80 mm Hg or higher, an ScvO2 of 70% or more, and a lactate level of less than 2.5 mmol/L. Targeted temperature management (32° to 36°C) for 24 to 48 hours is recommended in patients that remain comatose after ROSC and if advanced critical care capability is available. Additional neuroprotective strategies include permissive hypothermia, slow rewarming, osmotic therapy, and seizure prophylaxis. Critically ill survivors should be referred to veterinary critical care centers for PCA care. Prognostication depends on precipitating pathology, ongoing severity of illness, and neurological dysfunction. Neurological prognostication is unreliable before 24–72 hours after ROSC, and allowing enough time before making a euthanasia decision for neurological futility is reasonable unless financial constraints are a factor.