Date and Time: Tuesday, 17 March 2009, 6:00pm - 8:00pm
Location: Lecture theatre, M Block, Queen Elizabeth Hospital
Among post-cardiac arrest victims, the survival rate remained low despite recent advancement in basic life support and advanced life support. The in-hospital mortality rate ranged from 65-75% in Western countries.
Post-cardiac arrest syndrome was recognized after resumption of spontaneous circulation which was an unnatural pathophysiological state after successful cardiopulmonary resuscitation. The syndrome is composed of myocardial dysfunction, brain dysfunction, ischemia/reperfusion injury and underlying pathology that precipitating cardiac arrest.
Myocardial dysfunction is a stunning phenomenon which was responsive to treatment and reversible within days. Neuronal injury is selectively located at cerebral cortex, cerebellum, thalamus and hippocampus. A variety of cell death signaling pathways can execute over hours to days after cardiac arrest despite the predominant pathway causing brain injury remained controversial. Immunological heightening, endothelial damage, abnormal coagulopathy and hypercytokinemia in ischemia/reperfusion injury resemble severe septic shock, and victims are at risk of multiple organs failure and infection.
Post-cardiac arrest care is a time-sensitive issue, both inside and outside hospital. The care focuses on reversing the pathophysiological manifestations of the post- cardiac arrest syndrome with proper prioritization. Optimization of post-cardiac arrest care aims at improving survival and neurological outcome.
Concept of early-directed goal hemodynamic optimization after cardiac arrest is emerging to optimize the restoration and balance of oxygen delivery and demand. This concept is in close analogy to Rivers' early goal directed therapy in septic shock.
Early percutaneous cardiac intervention to coronary artery is advisable if coronary artery disease is the culprit of cardiac arrest. The evidence-based therapy in improving outcomes in post-cardiac arrest victims is therapeutic mild hypothermia. Cooling to 32-34C for 12-24 hours in selective patients improved survival and neurological recovery. However, ideal candidate, technique, target temperature, duration, and rewarming rate had not yet established. How hypothermia affects the outcome prediction of comatous survivors needs further investigation.
No well-designed clinical study on optimal glycemic control addressed to post-cardiac arrest patient specifically, although tight glycemic control in studies by Van den Bergh showed better survival outcome in ICU patients. Modest glycemic control (6-8mmol/L) is considered as the clinical bottom line without frequent hypoglycemia.
Bundle care to patients including airways and ventilation management, early-goal directed hemodynamic optimization, early reperfusion, control body temperature, blood glucose and seizure is the key to manage post-cardiac arrest patients.
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Dr Tong Wing Lok
Left: the audience, Right: Dr TSANG Hin Hung
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CCM Interhospital Meeting
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Speaker: Dr TONG Wing Lok; Associate Consultant (ICU), Kwong Wah Hospital
Chairman: Dr TSANG Hin Hung; Senior Medical Officer (ICU), Kwong Wah Hospital