[en] Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006-2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1-2) versus poor (CPC 3-5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46-0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.
Disciplines :
Anesthesia & intensive care
Author, co-author :
Düring, Joachim; Department of Clinical Sciences, Anesthesia & Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden. joachim.during@gmail.com
Annborn, Martin; Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
Dankiewicz, Josef; Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
Dupont, Allison; Department of Cardiology, Northside Cardiovascular Institute, Atlanta, GA, USA
Forsberg, Sune; Department of Intensive Care, Norrtälje Hospital, Karolinska Institute, Norrtälje, Sweden ; Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden
Friberg, Hans; Department of Clinical Sciences, Anesthesia & Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
Kern, Karl B; Division of Cardiology Department of Medicine, University of Arizona, Tucson, AZ, USA
May, Teresa L; Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
McPherson, John; Vanderbilt University Medical Center, Nashville, USA
Patel, Nainesh; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
Seder, David B; Division of Cardiology Department of Medicine, University of Arizona, Tucson, AZ, USA
STAMMET, Pascal ; University of Luxembourg > Faculty of Science, Technology and Medicine (FSTM) > Department of Life Sciences and Medicine (DLSM) > Medical Education ; Department of Intensive Care Medicine, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
Sunde, Kjetil; Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Søreide, Eldar; Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway ; Department of Clinical Medicine, University of Bergen, Bergen, Norway
Ullén, Susann; Clinical Studies Sweden- Forum South, Skåne University Hospital, Lund, Sweden
Nielsen, Niklas; Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
Hans-Gabriel & Alice Trolle-Wachtmeisters Foundation for Medical Research Regional research grants from the council of Skåne Government funding of clinical research within the Swedish National Health Services -ALF National Institutes of Health Stig and Ragna Gorthon foundation Lund University
Funding text :
Open access funding provided by Lund University. The INTCAR registry was supported by research grants from Stig and Ragna Gorthon Foundation, Hans-Gabriel & Alice Trolle-Wachtmeisters Foundation for Medical Research, Regional research grants from the council of Skåne and government funding of clinical research within the Swedish National Health Services (ALF), and in part by NIH U54GM115516: nne-ctr.net». The funding organizations did not have any access to the data, nor did they have any influence on data analysis or interpretation.
Dragancea, I., Rundgren, M., Englund, E., Friberg, H. & Cronberg, T. The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 84, 337–342. 10.1016/j.resuscitation.2012.09.015 (2013). DOI: 10.1016/j.resuscitation.2012.09.015
Nolan, J. P. et al. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 79, 350–379. 10.1016/j.resuscitation.2008.09.017 (2008). DOI: 10.1016/j.resuscitation.2008.09.017
Nielsen, N. et al. Targeted temperature management at 33 °C versus 36 °C after cardiac arrest. N. Engl. J. Med. 369, 2197–2206. 10.1056/NEJMoa1310519 (2013). DOI: 10.1056/NEJMoa1310519
Lascarrou, J. B. et al. Targeted temperature management for cardiac arrest with nonshockable rhythm. N. Engl. J. Med. 381, 2327–2337. 10.1056/NEJMoa1906661 (2019). DOI: 10.1056/NEJMoa1906661
Lemiale, V. et al. Intensive care unit mortality after cardiac arrest: The relative contribution of shock and brain injury in a large cohort. Intensive Care Med. 39, 1972–1980. 10.1007/s00134-013-3043-4 (2013). DOI: 10.1007/s00134-013-3043-4
Annborn, M. et al. The association of targeted temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: A post hoc analysis of the target temperature management trial. Intensive Care Med. 40, 1210–1219. 10.1007/s00134-014-3375-8 (2014). DOI: 10.1007/s00134-014-3375-8
Perkins, G. D. et al. Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: A Statement for Healthcare Professionals From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Resuscitation 96, 328–340. 10.1016/j.resuscitation.2014.11.002 (2015). DOI: 10.1016/j.resuscitation.2014.11.002
Grand, J. et al. Cardiac output, heart rate and stroke volume during targeted temperature management after out-of-hospital cardiac arrest: Association with mortality and cause of death. Resuscitation 142, 136–143. 10.1016/j.resuscitation.2019.07.024 (2019). DOI: 10.1016/j.resuscitation.2019.07.024
Oksanen, T. et al. Postresuscitation hemodynamics during therapeutic hypothermia after out-of-hospital cardiac arrest with ventricular fibrillation: A retrospective study. Resuscitation 85, 1018–1024. 10.1016/j.resuscitation.2014.04.026 (2014). DOI: 10.1016/j.resuscitation.2014.04.026
Huang, C. H. et al. Association of hemodynamic variables with in-hospital mortality and favorable neurological outcomes in post-cardiac arrest care with targeted temperature management. Resuscitation 120, 146–152. 10.1016/j.resuscitation.2017.07.009 (2017). DOI: 10.1016/j.resuscitation.2017.07.009
Torgersen, C. et al. Haemodynamic variables and functional outcome in hypothermic patients following out-of-hospital cardiac arrest. Resuscitation 84, 798–804. 10.1016/j.resuscitation.2012.10.012 (2013). DOI: 10.1016/j.resuscitation.2012.10.012
Nolan, J. P. et al. European resuscitation council and European society of intensive care medicine guidelines 2021: Post-resuscitation care. Resuscitation 161, 220–269. 10.1016/j.resuscitation.2021.02.012 (2021). DOI: 10.1016/j.resuscitation.2021.02.012
Nolan, J. P. et al. European resuscitation council and European society of intensive care medicine guidelines 2021: Post-resuscitation care. Intensive Care Med. 47, 369–421. 10.1007/s00134-021-06368-4 (2021). DOI: 10.1007/s00134-021-06368-4
Ameloot, K. et al. An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: Time to drop “one-size-fits-all” hemodynamic targets?. Resuscitation 90, 121–126. 10.1016/j.resuscitation.2015.03.001 (2015). DOI: 10.1016/j.resuscitation.2015.03.001
Ameloot, K. et al. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: The Neuroprotect post-cardiac arrest trial. Eur. Heart J. 40, 1804–1814. 10.1093/eurheartj/ehz120 (2019). DOI: 10.1093/eurheartj/ehz120
Jakkula, P. et al. Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: A randomised pilot trial. Intensive Care Med. 44, 2091–2101. 10.1007/s00134-018-5446-8 (2018). DOI: 10.1007/s00134-018-5446-8
Bray, J. E. et al. The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology. Resuscitation 85, 509–515. 10.1016/j.resuscitation.2013.12.005 (2014). DOI: 10.1016/j.resuscitation.2013.12.005
Young, M. N. et al. Higher achieved mean arterial pressure during therapeutic hypothermia is not associated with neurologically intact survival following cardiac arrest. Resuscitation 88, 158–164. 10.1016/j.resuscitation.2014.12.008 (2015). DOI: 10.1016/j.resuscitation.2014.12.008
Trzeciak, S. et al. Significance of arterial hypotension after resuscitation from cardiac arrest*. Crit. Care Med. 37, 2895–2903. 10.1097/CCM.0b013e3181b01d8c (2009). DOI: 10.1097/CCM.0b013e3181b01d8c
Grasner, J. T. et al. European resuscitation council guidelines 2021: Epidemiology of cardiac arrest in Europe. Resuscitation 161, 61–79. 10.1016/j.resuscitation.2021.02.007 (2021). DOI: 10.1016/j.resuscitation.2021.02.007
Brain Resuscitation Clinical Trial I Study Group. A randomized clinical study of cardiopulmonary-cerebral resuscitation: Design, methods, and patient characteristics. Brain Resuscitation Clinical Trial I Study Group. Am. J. Emerg. Med. 4, 72–86 (1986). DOI: 10.1016/0735-6757(86)90255-X
Peterson, R. A. & Cavanaugh, J. E. Ordered quantile normalization: A semiparametric transformation built for the cross-validation era. J. Appl. Stat. 47, 2312–2327. 10.1080/02664763.2019.1630372 (2020). DOI: 10.1080/02664763.2019.1630372
Pham, T. M., Carpenter, J. R., Morris, T. P., Wood, A. M. & Petersen, I. Population-calibrated multiple imputation for a binary/categorical covariate in categorical regression models. Stat. Med. 38, 792–808. 10.1002/sim.8004 (2019). DOI: 10.1002/sim.8004
Kilgannon, J. H. et al. Early arterial hypotension is common in the post-cardiac arrest syndrome and associated with increased in-hospital mortality. Resuscitation 79, 410–416. 10.1016/j.resuscitation.2008.07.019 (2008). DOI: 10.1016/j.resuscitation.2008.07.019
Gaieski, D. F. et al. Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation 80, 418–424. 10.1016/j.resuscitation.2008.12.015 (2009). DOI: 10.1016/j.resuscitation.2008.12.015
Sunde, K. et al. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73, 29–39. 10.1016/j.resuscitation.2006.08.016 (2007). DOI: 10.1016/j.resuscitation.2006.08.016
Ameloot, K. et al. Hemodynamic targets during therapeutic hypothermia after cardiac arrest: A prospective observational study. Resuscitation 91, 56–62. 10.1016/j.resuscitation.2015.03.016 (2015). DOI: 10.1016/j.resuscitation.2015.03.016
Annoni, F. et al. The impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients. Resuscitation 130, 167–173. 10.1016/j.resuscitation.2018.07.017 (2018). DOI: 10.1016/j.resuscitation.2018.07.017
Bro-Jeppesen, J. et al. Hemodynamics and vasopressor support during targeted temperature management at 33 °C versus 36 °C after out-of-hospital cardiac arrest: A post hoc study of the target temperature management trial*. Crit. Care Med. 43, 318–327. 10.1097/CCM.0000000000000691 (2015). DOI: 10.1097/CCM.0000000000000691
Chiu, Y. K., Lui, C. T. & Tsui, K. L. Impact of hypotension after return of spontaneous circulation on survival in patients of out-of-hospital cardiac arrest. Am. J. Emerg. Med. 36, 79–83. 10.1016/j.ajem.2017.07.019 (2018). DOI: 10.1016/j.ajem.2017.07.019
Laurikkala, J. et al. Mean arterial pressure and vasopressor load after out-of-hospital cardiac arrest: Associations with one-year neurologic outcome. Resuscitation 105, 116–122. 10.1016/j.resuscitation.2016.05.026 (2016). DOI: 10.1016/j.resuscitation.2016.05.026
Russo, J. J. et al. Optimal mean arterial pressure in comatose survivors of out-of-hospital cardiac arrest: An analysis of area below blood pressure thresholds. Resuscitation 128, 175–180. 10.1016/j.resuscitation.2018.04.028 (2018). DOI: 10.1016/j.resuscitation.2018.04.028
Janiczek, J. A. et al. Hemodynamic resuscitation characteristics associated with improved survival and shock resolution after cardiac arrest. Shock 45, 613–619. 10.1097/SHK.0000000000000554 (2016). DOI: 10.1097/SHK.0000000000000554
Mullner, M. et al. Arterial blood pressure after human cardiac arrest and neurological recovery. Stroke 27, 59–62. 10.1161/01.str.27.1.59 (1996). DOI: 10.1161/01.str.27.1.59
Beylin, M. E. et al. Higher mean arterial pressure with or without vasoactive agents is associated with increased survival and better neurological outcomes in comatose survivors of cardiac arrest. Intensive Care Med. 39, 1981–1988. 10.1007/s00134-013-3075-9 (2013). DOI: 10.1007/s00134-013-3075-9
Roberts, B. W. et al. Association between elevated mean arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest: Results from a multicenter prospective cohort study. Crit. Care Med. 47, 93–100. 10.1097/CCM.0000000000003474 (2019). DOI: 10.1097/CCM.0000000000003474
Lassen, N. A. Autoregulation of cerebral blood flow. Circ. Res. 15(Suppl), 201–204 (1964).
Sundgreen, C. et al. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke 32, 128–132. 10.1161/01.str.32.1.128 (2001). DOI: 10.1161/01.str.32.1.128
Sekhon, M. S., Ainslie, P. N. & Griesdale, D. E. Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: A “two-hit” model. Crit. Care 21, 90. 10.1186/s13054-017-1670-9 (2017). DOI: 10.1186/s13054-017-1670-9
