This section is focused on excerpts of pharmacotherapy recommendations discussed on the European Resuscitation Council and European Society of Intensive Care Medicine 2021 Guidelines for Post-resuscitation Care (1). 

To ensure a comprehensive understanding of post cardiac arrest care please read the open access full text.

Figure 2. Hemodynamic, oxygenation and ventilation targets (1).

Haemodynamic monitoring and management (1)

• All patients should be monitored with an arterial line for continuous blood pressure measurements, and it is reasonable to monitor cardiac output in hemodynamically unstable patients. 

• Perform early (as soon as possible) echocardiography in all patients to detect any underlying cardiac pathology and quantify the degree of myocardial dysfunction. 

• Avoid hypotension (<65 mmHg). Target mean arterial pressure (MAP) to achieve adequate urine output (>0.5 mL kg/h ) and normal or decreasing lactate. During TTM at 33º C, bradycardia may be left untreated if blood pressure, lactate, ScvO2 or SvO2 is adequate. If not, consider increasing the target temperature, but to no higher than 36º C. 

• Maintain perfusion with fluids, noradrenaline and/or dobutamine, depending on individual patient need for intravascular volume, vasoconstriction or inotropy. 

• Do not give steroids routinely after cardiac arrest. Avoid hypokalemia, which is associated with ventricular arrhythmias.

Seizure control (1)

• Use electroencephalography (EEG) to diagnose electrographic seizures in patients with clinical convulsions and to monitor treatment effects.  

• Guidelines recommend levetiracetam or sodium valproate as first-line antiepileptic drugs, in addition to sedative drugs, to treat seizures after cardiac arrest.

Routine seizure prophylaxis is not recommended in post-cardiac arrest patients. 

Seizure control (1)

• Use electroencephalography (EEG) to diagnose electrographic seizures in patients with clinical convulsions and to monitor treatment effects.  

• Guidelines recommend levetiracetam or sodium valproate as first-line antiepileptic drugs, in addition to sedative drugs, to treat seizures after cardiac arrest.

Routine seizure prophylaxis is not recommended in post-cardiac arrest patients. 

General intensive care management (1)

• Use short acting sedatives and opioids. 

• Avoid using a neuromuscular blocking drug routinely in patients undergoing TTM, but it may be considered in case of severe shivering during TTM. 

• Provide stress ulcer prophylaxis routinely in cardiac arrest patients. 

• Provide deep venous thrombosis prophylaxis. 

• Target a blood glucose of 140-180 mg/dL using an infusion of insulin if required; avoid hypoglycemia (<70 mg/dL). 

• Start enteral feeding at low rates (trophic feeding) during TTM and increase after rewarming if indicated. If TTM of 36 C is used as the target temperature, gastric feeding rates may be increased early during TTM. 

• We do not recommend using prophylactic antibiotics routinely.

Related drugs

• Sedatives / analgesia

  • Fentanyl

  • Propofol

  • Alfentanil

  • Remifentanil

• Vasopressors / inotropes

  • Epinephrine

  • Norepinephrine

  • Dobutamine

• Neuromuscular blockade

  • Rocuronium

  • Cisatracurium

• Seizure control

  • Levetiracetam

  • Sodium valproate

• Stress ulcer prophylaxis

  • Omeprazole

  • Esomeprazole

• Deep venous thrombosis prophylaxis

  • Unfractionated heparin

  • Enoxaparin

  • Dalteparin

  • Bivalirudin

  • Fondaparinux

References

1. Nolan JP, Sandroni C, Böttiger BW, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med. 2021;47(4):369-421. doi:10.1007/s00134-021-06368-4
   Springer - Intensive Care Medicine (Open Access)

Further reading on post cardiac arrest care

• AHA Guidalines on post-cardiac arrest care

  • Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published correction appears in Circulation. 2017 Sep 5;136(10 ):e197]. Circulation. 2015;132(18 Suppl 2):S465-S482. doi:10.1161/CIR.0000000000000262
    Circulation (Open Access)

• Seizure Prophylaxis

  • Cronberg T, Skrifvars M, Nolan J, Andersen LW, Berg KM, Böttiger BW, Callaway CW, Deakin CD, Donnino MW, Drennan I, Hsu C, Morely P, Nicholson TC, O’Neil BJ, Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Soar J, Wang TL, Welsford M, Neumar RW. Post-Cardiac Arrest Seizure Prophylaxis and Treatment Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2020 January 5th. Accessed March 11, 2023.
    ILCOR (Open Access)

• Prophylactic antibiotics

  • Couper K, Yeung K, Soar J, Berg K, Andersen LW, Böttiger BW, Callaway CW, Deakin CD, Donnino M, Drennan I, Hsu CH, Morley PT, Neumar RW, Nicholson TC, O’Neil BJ, Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Wang TL, Welsford M, Nolan JP. Prophylactic antibiotics following return of spontaneous circulation in adults: Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 3 January 2020. Accessed March 11, 2023.
    ILCOR (Open Access)