Post Cardiac Arrest: Blood Pressure Control
Cardiovascular, Critical Care / Resuscitation
- Survival varies from 8 – 19% in treated out-of-hospital cardiac arrests even in high performing systems.1
- Recent reports have demonstrated significant improvements in outcomes over the past decade,1 likely due to large scale improvements in OHCA care. Post arrest care likely has important impacts on survival, but precise recommendations of best practice are not clear for many clinical questions.
- There is no robust evidence from clinical trials testing the outcomes of differing blood pressure targets or specific therapies for blood pressure modification. Observational data has shown that hypotension is associated with increased mortality, however it may be a marker of illness severity rather than a modifiable risk factor.2
- Results from two studies that reported before-and-after evaluations of bundles of care including blood pressure targets, suggest that goal directed blood pressure control leads to improved outcomes.3,4
Recommended Hemodynamic Goals
- Target a mean arterial pressure (1/3 Systolic BP + 2/3 Diastolic BP) greater than 65 mmHg, or systolic blood pressure greater than 90 mmHg.
- Correct volume deficit if the patient is hypovolemic.
- Ensure no mechanical restriction in flow (pericardial tamponade, tension pneumothorax, pulmonary embolus) is contributing.
- If clinically euvolemic, support with norepinephrine infusion.
- Available evidence suggests that peripheral infusion of vasopressors at or proximal to the antecubital fossa is safe for the first two hours.5 Complications are most common after 12-24 hours.
- The reversal agent if extravasation occurs is Phentolamine.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- Patients should be transferred as soon as feasible to a regional critical care setting, ideally capable of invasive coronary procedures.
More Detailed Information
- Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient
- Part 8: Post–Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Daya MR, Schmicker RH, Zive DM, et al. Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015;91:108-115. doi:10.1016/j.resuscitation.2015.02.003.
Beylin ME, Perman SM, Abella BS, et al. Higher mean arterial pressure with or without vasoactive agents is associated with increased survival and better neurological outcomes in comatose survivors of cardiac arrest. Intensive Care Med. 2013;39(11):1981-1988. doi:10.1007/s00134-013-3075-9.
Sunde K, Pytte M, Jacobsen D, et al. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007;73(1):29-39. doi:10.1016/j.resuscitation.2006.08.016.
Gaieski DF, Band R a, Abella BS, et al. Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation. 2009;80(4):418-424. doi:10.1016/j.resuscitation.2008.12.015.
Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-17. doi:10.1016/j.jcrc.2015.01.014.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 21, 2018
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