Circulatory monitoring after successful cardiac resuscitation

The natural history of post-resuscitation myocardial dysfunction in human patients is not yet fully understood. However, the following hemodynamic abnormalities may indicate the presence of post-resuscitation myocardial dysfunction:

• increases in heart rate;

• decreases in arterial pressure and cardiac output;

• multiple ventricular arrhythmias;

• impaired myocardial work capability;

• acute ventricular dilation.

Routine hemodynamic and ECG monitoring, including the use of arterial cannulas, pulmonary artery flow-directed catheters, and echocardiographic studies, during the first 72 h following successful resuscitation are practical guides.

ECG monitoring is the standard practice in the measurement of heart rate and cardiac rhythm, with a 12-lead ECG preferred for monitoring post-resuscitation patients in the intensive care unit. Arrhythmias are the immediate cause of death during the first 72 h following initial successful resuscitation. Accordingly, continuous display of a standard electrocardiographic monitoring lead (II) is appropriate practice. The presence of arrhythmias and dysrhythmias such as premature ventricular complexes and supraventricular tachycardia requires clinical reassessment.

Continuous measurement of arterial pressure is recommended during the first 72 h after resuscitation. Arterial pressure reflects overall circulatory status but does not have diagnostic specificity.

The balloon-tipped flow-directed pulmonary artery catheter (Swan-Ganz catheter) allows for differentiation of cardiac failure from hypovolemia by evaluating filling pressures. Higher filling pressures are consistent with cardiac dysfunction. The catheter may be advanced through the subclavian, jugular, brachial, or femoral veins. Mean pulmonary artery pressure and pulmonary artery occlusion pressure may serve as indicators of left ventricular filling pressure, and a thermistor at the tip facilitates cardiac output measurements.

Chest radiography documents the position of endotracheal tubes and intravascular catheters, facilitates differential diagnosis of cardiogenic and non-cardiogenic pulmonary edema, and indicates changes in cardiac size. The effects of increased ventricular filling pressures may manifest with radiographic increases in pulmonary vascular congestion. Therefore serial chest radiographs are useful for the management of post-resuscitation patients.

Intermittent Doppler echocardiography has been a significant advance in monitoring the function of the heart, particularly in post-resuscitation patients. It provides quantitative assessment of both the structure and the function of the heart and great vessels by providing information on the systolic and diastolic functions of both left and right ventricles. Doppler echocardiography during the first 72 h after resuscitation allows for the early diagnosis of post-resuscitation myocardial dysfunction and the effects of therapy.

In addition, factors such as fever, anemia, acid-base balance, and electrolyte and endocrine abnormalities increase the heart rate and myocardial oxygen demand and lead to the further impairment of myocardial function following resuscitation. These factors should be identified and treated promptly.

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