What other therapies can we add?

Building a Bundle of Care

ACLS Pulseless

Arrest Algorithm

If pulse present begin post-resuscitation care

ACLS Post-

CardiacArrest

Algorithm

?

Cooling Curve

32

32.5

33

33.5

34

34.5

35

35.5

36

36.5

37

37.5

38

38.5

0 5 10 15 20 25 30 35 40 45 50 55 60

Hour

ROSC

Rewarming Begun

34°C

32°C

Electrolyte LossesHyperglycemia

Decreased HR, VO2

Decreased CO, diuresis

Hemodynamic recovery,increased O2 consumption

Increased K, decreased glucose

Hypothermia-induced Physiologic Changes/Resuscitation Opportunities

Shivering

Sepsis-like Syndrome

Fever Prevention and Neuroprognostication

Early Coronary Interventions

Myocardial Stunning

Resuscitation Medications,Oxygen

Target T°

Applying this knowledge to

post-arrest patients at Penn

CRSCenter for

Resuscitation Science

Define your Baseline

Identify the Champions

Write your Protocol

Educate,Disseminate

Be at the Bedside

Monitor Progress

Components of Comprehensive Care Bundle

• Heart Attack Early Cath Lab

• Early Hemodynamic Optimization

• Therapeutic Hypothermia

• Glucose Management Protocol

• Protect the Lungs

• Is the patient irreversibly injured? Appropriate Neuroprognostication

Combined hypothermia and early goal-directed therapy

bundle compared to historic controls

Cooled any rhythm, both in and out of hospital arrest

Target temperature 33oC, maintained for 24 hrsCPC 1-2 survivors

Before protocol After protocol 22% 44%

Studying bundled care

Gaieski et al. Resuscitation, 2009

Outcomes Data—240 patients

74% Neurologically intact

The goal: future developments

Time

% S

urvi

ving

ROSC

Hospitaldischarge

Arrest!

Gaieski et al. Crit Care Clin, 2011

Potential Therapies:•Optimal post-arrest bundle •Early ECPB•Mitochondrial Medicine•Suspended Animation•Regionalization

Survival >50%?CPR