The primary cardiovascular concern for post-cardiac arrest patients is the myocardial ischemia resulting from the arrest. It causes circulatory dysfunction that can last for hours after successful resuscitation in which the patient achieves a return of spontaneous circulation. 

The goals of supporting the cardiovascular system in post-cardiac arrest care are to maintain adequate:

• blood pressure
• cardiac output
• tissue perfusion
• preload by maintaining intravascular volume
• hemoglobin concentration
• SpO₂ and PaO₂

The team must address and treat myocardial dysfunction and arrhythmias while reducing the body’s metabolic demands.

Cardiovascular Assessment

Cardiac rate and rhythm, blood pressure, pulse pressure, pulse oximetry, urine output, and temperature are closely monitored throughout the post-cardiac arrest period. 

Blood pressure monitoring via an arterial line is preferred to a cuff monitoring system. The provider may also insert a central line to monitor central venous pressure, central venous oxygen saturation, and venous oxygenation to ensure tissue perfusion is adequate. An echocardiogram can evaluate the heart’s cardiac output. 

The team must perform recurring physical examinations of central and peripheral pulses, heart rate, capillary refill, and the color and temperature of the extremities. Neurologic function, renal function, and skin perfusion are indicators of end-organ function. 

Arterial and venous blood gas testing evaluates the child’s oxygenation and ventilation status. A complete blood count determines whether the patient has an adequate hemoglobin concentration. Glucose, electrolyte, and calcium results are used to evaluate the child’s metabolic status. Renal function can be evaluated by measuring creatinine and blood urea nitrogen. Lactate and central venous O₂ saturation are indicators of adequate tissue perfusion. Cardiac troponins are usually high after cardiac arrest.

Persistent metabolic acidosis and increased lactate suggest that the patient’s cardiac output is inefficient. Comparing the oxygen concentration of arterial blood with venous blood is an indicator of the patient’s perfusion status. If arterial oxygen saturation is high and venous oxygen saturation is low, perfusion of oxygen at the tissue level is poor.

Cardiovascular Management

The child’s blood pressure must be maintained by supporting the intravascular fluid volume. IV fluid therapy is the mainstay of treatment. An isotonic crystalloid solution can be given via two venous catheters at a volume of 10–20 mL/kg. Smaller fluid bolus amounts (5–10 ml/kg) can be considered when there are signs of cardiac or pulmonary edema. 

Each fluid bolus can be repeated until the desired effect is achieved. If the patient’s blood pressure has not improved after bolus fluid therapy, then vasoactive medications are necessary and should be titrated to achieve the desired blood pressure.

Oxygen supplementation should be titrated to meet a target SpO₂ of 94–99%. If the patient has a low hemoglobin, it may be necessary to transfuse packed RBCs to maintain arterial oxygen content.

Mechanical ventilation can reduce metabolic stress by decreasing the respiratory effort and metabolic tissue demand. Pain, fever, and agitation increase metabolic demand. Analgesics such as fentanyl and morphine and antipyretics may help reduce metabolic demand. Midazolam and lorazepam can be used to address the patient’s anxiety or agitation. 

Tachyarrhythmias and bradyarrhythmias must be addressed immediately and treated aggressively. A bradyarrhythmia that produces a heart rate < 60 bpm is a sign of cardiopulmonary failure. If supplementary oxygen and adequate ventilation fail to improve the heart rate, high-quality CPR must be initiated. 

Antiarrhythmics and electrical therapies are the treatments of choice for arrhythmias not responsive to oxygen and ventilation. Reversible causes (Hs and Ts) must also be addressed. A pediatric cardiologist’s expert care is necessary for all pediatric patients with arrhythmias and after a cardiac arrest event.

Myocardial dysfunction is common in the first 24 hours after achieving ROSC. Acidosis, hypocalcemia, and hypoglycemia all contribute to myocardial dysfunction, and the team must correct these immediately. Vasoactive agents and other interventions that reduce afterload are the treatment of choice. Mechanical ventilation with positive end-expiratory pressure can improve left ventricular function.

Optimizing Systemic Perfusion

Elements to optimize systemic perfusion