Cardiovascular Critical Care II

iii.

Emergent coronary angiography is no longer recommended over a delayed/selective

strategy in patients with ROSC after cardiac arrest. Exceptions exist for patients

with ST-segment–elevation myocardial infarction, shock, electrical instability, signs

of significant myocardial damage, or ongoing ischemia (Circulation 2024;149:e254-

73). An analysis suggests that risk stratification and admission prognosis can

help determine which patients will benefit from angiography (JACC Cardiovasc Interv

2018;11:249-56).

iv.

Effects of antiplatelet and antithrombotic drugs augmented by derangements in normal platelet

activation/coagulation pathways caused by hypothermia.

See the Cardiology chapter for the workup and treatment of acute coronary syndromes.

Optimize mechanical ventilation.

Goal arterial oxygen saturation is 94% or greater. A recent study found equivocal results

with restrictive (Pao2 target of 68–75 mm Hg) versus liberal (Pao2 target of 98–105 mm Hg)

oxygenation targets in comatose survivors of OHCA (N Engl J Med 2022;387:1456-66).

ii.

Avoid hyperventilation or over-bagging to avoid increase in intrathoracic pressure and decrease

in cardiac output.

iii.

Goal Paco2 is 40–45 mm Hg or Petco2 35–40 mm Hg.

Vasopressor/inotropes to support end-organ perfusion (see Table 6)

bicarbonate because they are inactivated (Hosp Pharm 1969;4:14-22).

extravasation and tissue necrosis.

Medication

Typical Dosing

Range

(mcg/kg/min)

Clinical Pearls

Epinephrine

0.03–0.3

Mixed α and β (1 > 2) activity

Used to treat severe hypotension (e.g., SBP < 70 mm Hg)

Used for symptomatic bradycardia

Used for hemodynamically unstable anaphylactic reactions

Higher doses associated with increased α1 activity

Norepinephrine

0.03–0.3

α > β (1 > 2) receptor activity

Used to treat severe hypotension (e.g., SBP < 70 mm Hg)

Should be used in volume-resuscitated patients

First line for septic shock

Higher doses associated with increased α1 activity

Phenylephrine

0.3–3

Pure α-agonist

Used to treat severe hypotension (e.g., SBP < 70 mm Hg)

Should be used in volume-resuscitated patients

Avoid in patients with low cardiac output