Abstract
Background: There is no consensus about the optimal strategy of hemodynamic support after cardiac arrest (CA) though some preclinical work supports higher perfusion pressures. We hypothesized that goal directed resuscitation after ROSC aimed at improving cardiac index (CI) ≥2 lpm/m 2 and achieving mean arterial pressures (MAP) ≥80 mm Hg could improve lactate clearance and potentially clinical outcomes. Methods: We began a quality improvement initiative within all ICUs of a single hospital by designing and educating staff about a hemodynamic resuscitation protocol. Patients on protocol had cardiac index (CI) and stroke volume variability (SVV) calculated using pulse pressure analysis of their arterial waveform (Vigeleo, Edwards Scientific). Patients received volume boluses (SVV≥13%) or inotropes (SVV<13%; CI<2) or vasopressors (SVV<13%; MAP<80) to achieve goals. Lactate levels were checked q2 hour for initial 6h then q6 h for the next 24h. Fluid intake and output were recorded hourly. These were ICU standards. 18 patients managed on the protocol were propensity matched with 18 historical controls from the last year on the basis of initial lactate, MAP, cumulative vasopressor index (CVI) and Pittsburgh Cardiac Arrest Category (PCAC). 6h lactate clearance, mean MAP and CVI, fluid balance and inotrope use were measured as well as survival to hospital discharge. Comparisons were by Mann Whitney U test. Results: Protocol patients were well matched with controls ( Table 1): Protocol patients showed trends towards better lactate clearance and higher MAP, attributable to higher fluid delivery and lower vasopressor and inotrope use. Survival between groups was unchanged (27.8% protocol Vs 22.2% control). Conclusion: Goal directed resuscitation to optimize CI and MAP resulted in more fluid administration achieving higher blood pressures with less inotrope and pressor use. Greater power is needed to conclude clinical benefit but the strategy is promising.
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