Hemodynamic Monitoring and Management of the Hypotensive Out-of-Hospital Cardiac Arrest Patient in the Adult Intensive Care Unit.

Out-of-hospital cardiac arrest (OHCA) represents a major public health challenge, with high mortality and significant neurological impairments among survivors. Hemodynamic instability, particularly hypotension (a mean arterial blood pressure <65mmHg), may be a key contributor to post-resuscitation morbidity and mortality. After return of spontaneous circulation, hypotension can result from various causes, including arrhythmias, mechanical complications, thromboembolism, or different types of shock, as well as sedation, temperature control and positive pressure ventilation. Differentiating between hypotension with vs. without hypoperfusion is critical to avoid unnecessary interventions while ensuring adequate cerebral and myocardial perfusion. Clinical assessment and repeated echocardiography should be routine in all patients. Therapeutic targets should include evidence of preserved end-organ function, including urine output, and normal or decreasing lactate. In selected cases, advanced hemodynamic monitoring with pulmonary artery catheters may be necessary to diagnose the shock-type and monitor treatment effects. Causal treatment of the precipitating cause of hypotension is crucial as well as symptomatic treatment with fluids, vasopressors and inotropes if needed. Mechanical circulatory support may be employed for refractory shock unresponsive to other treatment. This clinical consensus statement by the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology (ESC) provides clinical guidance for the hemodynamic monitoring and management of hypotension in OHCA patients in intensive care. The document advocates for a multidisciplinary approach that integrates clinical assessment, imaging, and hemodynamic parameters to guide treatment, with the overarching goal of improving survival rates and neurological outcomes.