Goal-Directed Postresuscitation Therapies
Robert A. Berg, MD, FCCM; Vinay M. Nadkarni, MD, FCCM
Objectives
● Learn the epidemiology of pediatric cardiac arrest
● Review the 4 phases of cardiac arrest
● Review goal-directed postresuscitation-induced mild
hypothermia
● Learn about postresuscitation myocardial dysfunction
and its treatment
● Review postresuscitation blood pressure control
● Learn about extracorporeal membrane oxygenation- before resuscitation, the initial electrocardiographic rhythm
cardiopulmonary resuscitation and its relevance to post-
resuscitation care
Key words: cardiac arrest; defibrillation; extracorporeal
membrane oxygenation; heart arrest; hypothermia;
postresuscitation myocardial dysfunction; ventricular
fibrillation
Epidemiology of Cardiac Arrest in Children
Cardiovascular disease remains the most common cause
of disease-related death in the United States, resulting in
approximately 1 million deaths per year. It is estimated that
400,000 to 460,000 North Americans will die of cardiac
arrest each year, nearly 90% outside of hospital settings.
Data regarding the incidence of unexpected childhood
cardiopulmonary arrest is less robust, but the best recent
data suggest that approximately 16,000 American children
suffer a cardiac arrest each year, with an annual incidence processes and limitations in technologic support and
of roughly 8 to 20 per 100,000 children. Bystander cardio-
pulmonary resuscitation (CPR) is provided only to
approximately 30% of pediatric cardiac arrest victims before
reaching the hospital, so it is not surprising that the
outcome from out-of-hospital cardiac arrest in children has
been reported to be very poor.
Pediatric cardiac arrests most frequently result from
global asphyxia secondary to evolving respiratory failure
(hypoxia and ischemia), rather than from a sudden arrhyth-
mic cardiac event. The incidence of pediatric pulseless arrest
is difficult to estimate because of inconsistent resuscitation
report terminology, difficulty in assessing and verifying
pulselessness in children, and the lack of prospective,
controlled trials of interventions for selected cohorts of
patients who have resuscitation potential. Approximately
5% of newborn infants require some degree of basic life
support in the delivery room, but only 0.12% require chest
compressions and/or administration of epinephrine.
Neonatal asphyxia accounts for 1 million deaths annually
worldwide. Cardiac arrest occurred in 3% of children
admitted to one children’s hospital, in 1.8% of all children
admitted to pediatric intentive care units (PICUs), and in
4% of children admitted to a pediatric cardiac ICU.
Depending on the setting of pediatric cardiac arrest, initial
return of spontaneous circulation (ROSC) occurs in 5 to
64%, with a wide range (20-83%) of reported long-term
neurologic sequelae in survivors. Survival rates differ
dramatically depending on the timing, intensity, and
duration of cardiac arrest and interventions provided.
Critical factors that influence survival outcomes include the
child’s pre-existing condition, the environment in which
arrest occurs, the duration of the absence of blood flow
detected, and the quality of the basic and advanced life
support interventions provided. Long-term survival in
pediatric out-of-hospital cardiac arrest is generally reported
as < 5%, while survival following arrest in a PICU ranges
from 15 to 27%. Survival following cardiac arrest in special
resuscitation circumstances, such as pediatric cardiac ICU
environments, can be as high as 44%; following bradycardia
requiring chest compressions in a neonatal intentive care
unit (NICU), it can be as high as 51%.
Several well-designed in-hospital pediatric CPR
investigations with long-term follow-up have established
that pediatric CPR and advanced life support can be
remarkably effective (Table 1). Fifty percent to 75% of
patients consistently achieve initial successful return of
spontaneous circulation in > 20 minutes (ie, sustained
ROSC). Approximately 25 to 50% of these initial survivors
survive to hospital discharge. Survival decreases progres-
sively with time, in large part due to the underlying disease
aggressive interventions. Most of these reported events
occur in PICUs and are caused by progressive life-threaten-
ing illnesses that have not responded to treatment despite
critical care monitoring and supportive care. Reported 1-
year survival rates of 10 to 44% are superior to outcomes
from out-of-hospital pediatric CPR (generally 2 to 14%)
and substantially superior to the certain death seen if CPR
and advanced life support were not provided. Most impor-
tantly, most long-term survivors have good neurologic
outcomes (ie, normal or no demonstrable change in their
neurologic status before arrest).
The National Registry of Cardiopulmonary Resuscitation
(NRCPR) is an American Heart Association-sponsored,
prospective, multi-site, observational study of in-hospital
resuscitation, currently the largest registry of its kind
in the world. The NRCPR is the first comprehensive,
Utstein-style, standardized characterization of in-hospital
resuscitation in the United States. Among the first 1,005
consecutive pediatric pulseless cardiac-arrest index events
submitted to the NRCPR from 82 U.S. hospitals ( January
2000 through June 2004), 90% had initial asystole or
pulseless electrical activity and 10% had initial ventricular
Goal-Directed Postresuscitation Therapies 
 fibrillation/ventricular tachycardia (VF/VT). A total of
27% of patients had VF/VT at some time during the
arrest. Among the patients with asystole/pulseless electrical
activity, 51% had ROSC > 20 minutes and 27% survived
to hospital discharge. Among the patients with initial
VF/VT, 69% had ROSC > 20 minutes and 34% survived
to hospital discharge. These outcomes in the 21st century
are substantially superior to reports in the 1980s and 1990s.
Unfortunately, the nature of the data does not allow us
to address the important issues of whether the improved
outcomes are related to better Pediatric Advance Life
Support (PALS) guidelines, better adherence to guideline-
based goal-directed therapy, better postresuscitation care, outcome. Optimal CPR is frequently not provided, even in
or other factors.
Four Phases of Cardiac Arrest and CPR
There are 4 phases of cardiac arrest with common
features in infants, children and adults: (1) pre-arrest; (2) no
flow (untreated cardiac arrest); (3) low flow (CPR); and (4)
post-resuscitation. Interventions to improve outcome from
pediatric cardiac arrest should optimize therapies targeted
to the time and phase of CPR as suggested in Table 2.
Identification of these 4 distinct phases of cardiac arrest and
CPR suggest the opportunity to focus the timing, selection,
intensity, and duration of resuscitation interventions to the
physiology and metabolic state of the cardiac arrest patient.
The pre-arrest phase includes pre-existing conditions
(eg, neurologic, cardiac, respiratory, infectious, or metabolic
problems), developmental status (eg, premature neonate,
mature neonate, infant, child, or adolescent), and precipitat-
ing events (eg, respiratory failure or shock). It may represent
a period of low, normal, or high blood flow. Interventions
during the pre-arrest phase focus on prevention, with
special attention to early recognition and treatment of
respiratory failure and shock in children. Specifically, the
mobilization of medical emergency response teams to
address rapid restoration of oxygenation, ventilation, and
monitoring may improve outcome.
Interventions during the no-flow phase of untreated
Table 1. Summary of Representative Studies of Outcome Following Pediatric Cardiac Arrest
# of Return of Spontaneous
Author, year Setting
patients Circulation (ROSC)
Reis 2002 In hospital CA 129 83 (64%)
Nadkarni 2005 In hospital CA 286 119 (42%)
In Hospital PICU
Slonim 1997 205 not reported
CA
In hospital RA CA 53
Zaritsky A 1987 not reported
or CA RA 40
Pediatric cardiac
Parra 2000 32 24/38 arrests (63%)
ICU CA
Cardiac arrest, CA; respiratory arrest, RA
 Pediatric Multiprofessional Critical Care Review
cardiac arrest focus on early recognition of cardiac arrest,
effective monitoring, and prompt initiation of basic and
advanced life support. Effective CPR attempts to optimize
coronary perfusion pressure and cardiac output to critical
organs to support vital organ viability during the low-flow
phase. Basic life support with continuous effective chest
compressions (ie, push hard, push fast, allow chest recoil,
minimize interruptions, and don’t overventilate) is the
emphasis in this phase. Optimal coronary perfusion
pressure, exhaled carbon dioxide and cardiac output during
the low-flow phase of CPR is consistently associated with
improved ROSC and improved short- and long-term
highly monitored inpatient environments. For ventricular
fibrillation and pulseless ventricular tachycardia, rapid
determination of electrocardiographic rhythm and prompt
defibrillation are most important for successful resuscita-
tion. For cardiac arrests due to asphyxia and/or ischemia,
provision of adequate myocardial perfusion and myocardial
oxygen delivery is most important.
The postresuscitation phase includes immediate
postresuscitation management, the following hours to days,
and long-term rehabilitation. The immediate postresuscita-
tion stage is a high-risk period for ventricular arrhythmias
and other reperfusion injuries. Interventions during the
immediate postresuscitation stage and the following few
days target goal-directed therapies to match oxygen and
substrate delivery to meet metabolic tissue demand so as
to minimize reperfusion injury and support cellular
recovery. Overventilation is frequent and can have adverse
effects during and following CPR. Injured cells can
hibernate, die, or partially or fully recover function. The
postarrest phase may have the most potential for innovative
advances in the understanding of cell injury and death,
inflammation, apoptosis and hibernation, ultimately leading
to novel interventions. Thoughtful attention to the manage-
ment of temperature, glucose, blood pressure, coagulation,
ventilation, and carbon dioxide may be particularly
important in this phase. The rehabilitation stage concen-
Survival to Intact Neurologic
Discharge Survival
21 (16%) 19 (15%)
65 (23%) 44 (15%)
28 (14%) not reported
CA 5 (9%)
not reported
RA 27 (68%)
14/32 patients
8/32 (25%)
(44%)
Table 2. Therapies to Improve Pediatric Cardiac Arrest

Phase Interventions
• Community education regarding child safety
Pre-Arrest
• Early diagnosis and treatment of respiratory failure and/or shock
Phase
• Monitor high-risk in-patients
• Medical emergency response teams
Arrest (no-flow) • Minimize interval to BLS and ACLS
Phase • Effective 911/Code Blue Response system
• Minimize interval to defibrillation, when indicated

Low-Flow (CPR) • Effective CPR to optimize myocardial blood flow and cardiac output
Phase • Avoid interruptions in cheast sompressions and overventilation
• Consider Extracorporeal CPR if standard CPR/ALS are not promptly successful

• Optimize cardiac output and cerebral perfusion

Postresuscitation • Treat arrhythmias, if indicated
Phase • Avoid hyperglycemia, hyperthermia
• Consider mild resuscitative systemic hypothermia (for 24-48 hours following resuscitation)
• Possible future role for anti-oxidants, anti-inflammatory agents, thrombolytics, mediators of
hibernation, and modulation of excitatory neurotransmitters

trates on salvage of injured cells, recruitment of hibernating
cells, and re-engineering of reflex and voluntary communi-
cations in these cell and organ systems to improve
functional outcome.
The specific phase of resuscitation should dictate the
timing, intensity, duration, and focus of interventions.
Emerging data suggest that interventions that can improve
short-term outcome during one phase may be deleterious
during another. For instance, intense vasoconstriction
during the low-flow phase of cardiac arrest may improve
coronary perfusion pressure and the probability of ROSC.
The same intense vasoconstriction during the postresuscita-
tion phase may increase left ventricular afterload and
worsen myocardial strain and dysfunction. Current under-
standing of the physiology of cardiac arrest and recovery
only enables the crude titration of blood pressure, global
oxygen delivery and consumption, body temperature,
inflammation, coagulation, and other physiologic indices European study. Similarly, in the study by Bernard et al,
in an attempt to optimize outcome. Future strategies likely
will take advantage of emerging discoveries and the
knowledge of cellular inflammation, thrombosis, reperfu-
sion, mediator cascades, cellular markers of injury and
recovery, and transplantation technology.
Postresuscitation Interventions
Temperature Management
Mild induced hypothermia is the most celebrated goal-
directed postresuscitation therapy for adults. Two articles
published in The New England Journal of Medicine on
February 21, 2002, established that mild induced hypother-
mia could improve outcome for comatose adults after
resuscitation from ventricular fibrillation cardiac arrest. In
both randomized controlled trials, the inclusion criteria
were patients older than 18 years who were persistently
comatose after successful resuscitation from nontraumatic
ventricular fibrillation. The multicenter European study, led
by Fritz Sterz and Michel Holzer, had a goal of 32°C to
34°C for the first 24 hours after arrest. The mean time until
attainment of this temperature goal was approximately 8
hours. Six-month survival with good neurologic outcome
was superior in the hypothermic group (75 of 136 vs 54 of
137; relative risk [RR], 1.40; confidence interval [CI], 1.08-
1.81). Similarly, death 6 months after the event occurred
less often in the hypothermic group (56 of 137 vs 76 of
138; RR, 0.74; CI, 0.58-0.95). In the same issue of The New
England Journal of Medicine, Bernard et al reported good
outcomes in 21 of 43 (49%) of the hypothermic group
compared to 9 of 34 (26%) of the control group (P = 0.046;
odds ratio, 5.25; CI, 1.47-18.76). Importantly, hypotension
occurred in over 50% of the patients in both groups and
was aggressively treated with vasoactive infusion in the
more than 50% of the patients received epinephrine
infusions during the first 24 hours postresuscitation.
How should these data effect postresuscitation treatment
after pediatric arrests? Fever following cardiac arrest is
associated with poor neurologic outcome. Hyperthermia
following cardiac arrest is common in children. It is
reasonable to believe that mild induced systemic hypother-
mia may benefit children resuscitated from cardiac arrest,
but benefit from this treatment has not been studied
rigorously and reported in children or in any patients with
non-VF arrests. At a minimum, it is advisable to strictly
avoid even mild hyperthermia in children following CPR.
Scheduled administration of antipyretic medications with
use of external cooling devices is often necessary to avoid
hyperthermia in this population.

Goal-Directed Postresuscitation Therapies 

 Postresuscitation Myocardial Support
Postarrest myocardial stunning occurs commonly after
successful resuscitation in animals, adults, and children. Assuming treatment of postresuscitation myocardial
In addition, most adults who survive to hospital admission
after an out-of-hospital cardiac arrest die in the postresusci-
tation phase, many due to progressive myocardial
dysfunction. Animal studies have demonstrated that the
postarrest myocardial stunning is a global phenomenon
with biventricular systolic and diastolic components, and
typically resolves after 1 or 2 days. This postarrest myocar-
dial stunning is pathophysiologically and physiologically
similar to sepsis-related myocardial dysfunction and
postcardiopulmonary bypass myocardial dysfunction,
including increases in inflammatory mediator and nitric
oxide production. Postarrest myocardial stunning is worse
after a more prolonged untreated cardiac arrest, after more
prolonged CPR, after defibrillation with higher energy
shocks, and after greater number of shocks.
In 1998, Mullner and colleagues demonstrated poor Compared to healthy volunteers, adults resuscitated
left ventricular function in all 20 adults surviving to ICU
admission after out-of hospital cardiac arrest. Similar to blood flow. Hence, they may not maintain cerebral
the data from the induced hypothermia studies noted
above, 17 of these patients were treated with vasoactive
infusions (epinephrine, dopamine, and/or dobutamine)
during the first 24 hours postresuscitation.
Optimal treatment of postarrest myocardial dysfunction
has not been established. As noted before, this myocardial
dysfunction has been treated with various continuous
inotropic/vasoactive agents, including dopamine, dobuta-
mine, and epinephrine, in both children and adults.
Prospective, controlled animal studies have documented
amelioration of myocardial dysfunction with postresuscita-
tion intravenous dobutamine infusions. In addition,
milrinone improves the hemodynamic status of children
with postcardiopulmonary bypass myocardial dysfunction
and septic shock. Milrinone has also improved postarrest
myocardial function in a swine model. Finally, the new
inotropic agent levosimendan has also been effective in
animal models of postresuscitation myocardial dysfunction.
Although prospective controlled trials in animals have
demonstrated that the myocardial dysfunction can be
effectively treated with vasoactive agents, there are no data
demonstrating improvements in outcome. Nevertheless,
because myocardial dysfunction is common and can lead to
secondary ischemic injuries in other organ systems or even
cardiovascular collapse, treatment with vasoactive medica-
tions is a rational therapeutic choice that may improve
outcome. The hemodynamic benefits in animal studies of
postarrest myocardial dysfunction, pediatric studies of
postcardiopulmonary bypass myocardial dysfunction, and
pediatric sepsis-related myocardial dysfunction support
the use of inotropic/vasoactive agents in this setting. In
addition, adult studies document the common occurrence
of postarrest hypotension and/or poor myocardial function
“requiring” inotropic/vasoactive agents. In summary, because
treatment of postarrest myocardial dysfunction with
inotropic/vasoactive infusions can improve the patient’s
 Pediatric Multiprofessional Critical Care Review
hemodynamic status, such treatment should be routinely
considered.
dysfunction is appropriate, what should be our therapeutic
goal? Should we aim for a normal echocardiographic
ejection fraction? Normal cardiac output? Normal blood
pressure? Normal mixed venous oxygen saturation? The
answers to these questions are not presently available. This
is a potentially rich area for further investigation.
Blood Pressure Management
As noted earlier, postresuscitation myocardial dysfunc-
tion is common and has many similarities to sepsis-
associated myocardial dysfunction. Therefore, it should not
be surprising that Laurent and colleagues (2002) demon-
strated that 55% of adults surviving out-of-hospital cardiac
arrests required in-hospital vasoactive infusions for hypo-
tension unresponsive to volume boluses.
from cardiac arrest have impaired autoregulation of cerebral
perfusion pressure in the face of systemic hypotension, and
likewise may not be able to protect the brain from acutely
increased blood flow in the face of systemic hypertension.
It is reasonable to presume that blood pressure variability
should be minimized as much as possible following
resuscitation from cardiac arrest.
A brief period of hypertension following resuscitation
from cardiac arrest may diminish the no-reflow phenom-
enon. In animal models, brief induced hypertension
following resuscitation results in improved neurologic
outcome compared to normotension. In a retrospective
human study, post-resuscitative hypertension was associated
with a better neurologic outcome after controlling for age,
gender, duration of cardiac arrest, duration of CPR, and
preexisting diseases.
Given these limited data, what should be our postresus-
citation blood pressure goals for children? It seems
reasonable to aggressively treat and prevent hypotension.
Moreover, severe hypertension would seem to be unattract-
ive. Any further assertions are difficult to support.
Glucose Control
Hyperglycemia following adult cardiac arrest is associ-
ated with worse neurologic outcome after controlling for
duration of arrest and presence of cardiogenic shock. In an
animal model of asphyxial cardiac arrest, administration of
insulin and glucose, but not administration of glucose alone,
improved neurologic outcome compared to administration
of normal saline. Should clinicians target tight glucose
control with avoidance of hyperglycemia and hypoglycemia
following pediatric cardiac arrests? Perhaps, but data
supporting this hope are not available.
ECMO-CPR
Perhaps the ultimate technology to control postresusci-
tation temperature and hemodynamic parameters is
extracorporeal membrane oxygenation (ECMO). The
concomitant administration of heparin may optimize
microcirculatory flow.
The use of veno-arterial ECMO to reestablish circula-
tion and provide controlled reperfusion following cardiac
arrest has been reported, but prospective, controlled studies
are lacking. Nevertheless, these series have reported
extraordinary results with the use of ECMO as a rescue
therapy for pediatric cardiac arrests, especially from
potentially reversible acute postoperative myocardial
dysfunction or arrhythmias. In one study, 11 children who
suffered cardiac arrest in the PICU after cardiac surgery
were placed on ECMO after 20 to 110 minutes of CPR.
Prolonged CPR was continued until ECMO cannulae,
circuits, and personnel were available. Six of these 11
children were long-term survivors without apparent
neurologic sequelae. More recently, 2 centers have reported
an additional (remarkable) 8 pediatric cardiac patients
provided with mechanical cardiopulmonary support within
20 minutes of the initiation of CPR. All 8 survived to
hospital discharge. CPR and ECMO are not curative
treatments. They are simply cardiopulmonary supportive
measures that may allow tissue perfusion and viability until
recovery from the precipitating disease process. As such,
they can be powerful tools.
Most remarkably, Morris and Nadkarni reported 66
children who were placed on ECMO during CPR at
Children’s Hospital of Philadelphia (CHOP) over 7 years.
The median duration of CPR before establishment of
ECMO was 50 minutes, and 35% (23 of 66) of these
children survived to hospital discharge. It is important to
emphasize that these children had brief periods of “no
flow,” excellent CPR during the “low-flow” period, and a
well-controlled postresuscitation phase.
How does this ECMO-CPR experience relate to
postresuscitation care? Potential advantages of ECMO
come from its ability to maintain tight control of physi-
ologic parameters after resuscitation. For example, blood
flow rates, oxygenation, ventilation, and body temperature
can be manipulated precisely through the ECMO circuit.
As we learn more about the processes of secondary injury
following cardiac arrest, ECMO might enable controlled
perfusion and temperature management to minimize
reperfusion injury and maximize cell recovery. Conversely,
maybe we should imitate ECMO goals for children
successfully resuscitated from cardiac arrest (eg, maintain
adequate Svo2).
Summary
Cardiopulmonary resuscitation can be remarkably
effective for children in cardiac arrest, resulting in successful
initial resuscitation of one half to two thirds of children
with in–hospital cardiac arrest. Nearly one half of these
children subsequently die in the postresuscitation period.
Goal-directed postresuscitation therapies hold great
promise for improving outcomes following cardiac arrest. arrests among children and adults: a report from the
In particular, induced mild hypothermia, myocardial
supportive care, avoidance of hypotension, glucose control,
and ECMO deserve consideration.
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