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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:1427-1438. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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2
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Zhao Y, Chen D, Wang Q. Lower Versus Higher Blood Pressure Targets in Critically Ill Patients. Crit Care Med 2024; 52:e487-e488. [PMID: 39145714 DOI: 10.1097/ccm.0000000000006343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Affiliation(s)
- Yang Zhao
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Da Chen
- Department of Emergency, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Qian Wang
- Department of Emergency, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
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3
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D'Amico F, Pruna A, Putowski Z, Landoni G. The authors reply. Crit Care Med 2024; 52:e488-e489. [PMID: 39145715 DOI: 10.1097/ccm.0000000000006375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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4
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Aneman A, Skrifvars MB, Ameloot K. Venous return physiology applied to post-cardiac arrest haemodynamic management: a post hoc analysis of the NEUROPROTECT trial. Intensive Care Med Exp 2024; 12:70. [PMID: 39138823 PMCID: PMC11322455 DOI: 10.1186/s40635-024-00657-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 08/07/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND The European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups. RESULTS Data from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [- 0.014-0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08-0.43] fraction units, p = 0.01). CONCLUSIONS Calculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.
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Affiliation(s)
- Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District and South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
- The Ingham Institute for Applied Medical Research, Sydney, Australia.
- Faculty of Health Sciences, Macquarie University, Sydney, Australia.
| | - Markus Benedikt Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Louvain, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
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5
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Kanaris C. Fifteen-minute consultation: A guide to paediatric post-resuscitation care following return of spontaneous circulation. Arch Dis Child Educ Pract Ed 2024:edpract-2023-325922. [PMID: 39122265 DOI: 10.1136/archdischild-2023-325922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
Paediatric resuscitation is a key skill for anyone in medicine who is involved in the care of children. Basic and advance paediatric life support courses are crucial in teaching those skills nationwide in a way that is memorable, protocolised and standardised. These courses are vital in the dissemination and upkeep of both theoretical and practical knowledge of paediatric resuscitation, with their primary aim being the return of spontaneous circulation. While sustaining life is important, preserving a life with quality, one with good functional and neurological outcomes should be the gold standard of any resuscitative attempt. Good neurological outcomes are dependent, in large part, on how well the postresuscitation stage is managed. This stage does not start in the intensive care unit, it starts at the point at which spontaneous circulation has been reinstated. The aim of this paper is to provide a basic overview of the main strategies that should be followed in order to minimise secondary brain injury after successful resuscitation attempts.
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Affiliation(s)
- Constantinos Kanaris
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
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6
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Tabi M, Perel N, Taha L, Amsalem I, Hitter R, Maller T, Manassra M, Karmi M, Zacks N, Levy N, Shrem M, Marmor D, Gavriel D, Jarjoui A, Shuvy M, Asher E. Out of hospital cardiac arrest - new insights and a call for a worldwide registry and guidelines. BMC Emerg Med 2024; 24:140. [PMID: 39095722 PMCID: PMC11297571 DOI: 10.1186/s12873-024-01060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
INTRODUCTION Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. METHOD We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020-2023. RESULTS A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1-2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. CONCLUSION Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.
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Affiliation(s)
- Meir Tabi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Nimrod Perel
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Louay Taha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itshak Amsalem
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rafi Hitter
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Maller
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mohamed Manassra
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mohammad Karmi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Netanel Zacks
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nir Levy
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Maayan Shrem
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Marmor
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Gavriel
- Vascular Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Amir Jarjoui
- Department of Medicine, Pulmonary Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mony Shuvy
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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7
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Perkins GD, Neumar R, Hsu CH, Hirsch KG, Aneman A, Becker LB, Couper K, Callaway CW, Hoedemaekers CWE, Lim SL, Meurer W, Olasveengen T, Sekhon MS, Skrifvars M, Soar J, Tsai MS, Vengamma B, Nolan JP. Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2024; 201:110196. [PMID: 38932555 DOI: 10.1016/j.resuscitation.2024.110196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.
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8
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Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2022. Am J Emerg Med 2024; 80:123-131. [PMID: 38574434 DOI: 10.1016/j.ajem.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/31/2024] [Indexed: 04/06/2024] Open
Abstract
The number of critically ill patients that present to emergency departments across the world has risen steadily for nearly two decades. Despite a decrease in initial emergency department (ED) volumes early in the COVID-19 pandemic, the proportion of critically ill patients is now higher than pre-pandemic levels [1]. The emergency physician (EP) is often the first physician to evaluate and resuscitate a critically ill patient. In addition, EPs are frequently tasked with providing critical care long beyond the initial resuscitation. Prolonged boarding of critically ill patients in the ED is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality [2-4]. Given the continued increase in critically ill patients along with the increases in boarding critically ill patients in the ED, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill patients continue to receive evidence-based care. This review summarizes important articles published in 2022 that pertain to the resuscitation and management of select critically ill ED patients. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and sepsis.
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Affiliation(s)
- Michael E Winters
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Kami Hu
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph P Martinez
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Haney Mallemat
- Internal Medicine and Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - William J Brady
- Departments of Emergency Medicine and Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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9
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Steinberg A. Emergent Management of Hypoxic-Ischemic Brain Injury. Continuum (Minneap Minn) 2024; 30:588-610. [PMID: 38830064 DOI: 10.1212/con.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. LATEST DEVELOPMENTS Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. ESSENTIAL POINTS Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.
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Preuß S, Multmeier J, Stenzel W, Major S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Survival, but not the severity of hypoxic-ischemic encephalopathy, is associated with higher mean arterial blood pressure after cardiac arrest: a retrospective cohort study. Front Cardiovasc Med 2024; 11:1337344. [PMID: 38774664 PMCID: PMC11106407 DOI: 10.3389/fcvm.2024.1337344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Background This study investigates the association between the mean arterial blood pressure (MAP), vasopressor requirement, and severity of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Methods Between 2008 and 2017, we retrospectively analyzed the MAP 200 h after CA and quantified the vasopressor requirements using the cumulative vasopressor index (CVI). Through a postmortem brain autopsy in non-survivors, the severity of the HIE was histopathologically dichotomized into no/mild and severe HIE. In survivors, we dichotomized the severity of HIE into no/mild cerebral performance category (CPC) 1 and severe HIE (CPC 4). We investigated the regain of consciousness, causes of death, and 5-day survival as hemodynamic confounders. Results Among the 350 non-survivors, 117 had histopathologically severe HIE while 233 had no/mild HIE, without differences observed in the MAP (73.1 vs. 72.0 mmHg, pgroup = 0.639). Compared to the non-survivors, 211 patients with CPC 1 and 57 patients with CPC 4 had higher MAP values that showed significant, but clinically non-relevant, MAP differences (81.2 vs. 82.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors (n = 54), who regained consciousness before death, had higher MAP values compared to those with no/mild HIE (n = 179), who remained persistently comatose (74.7 vs. 69.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors, who regained consciousness, required fewer vasopressors (CVI 2.1 vs. 3.6, pgroup < 0.001). Independent of the severity of HIE, the survivors were weaned faster from vasopressors (CVI 1.0). Conclusions Although a higher MAP was associated with survival in CA patients treated with a vasopressor-supported MAP target above 65 mmHg, the severity of HIE was not. Awakening from coma was associated with less vasopressor requirements. Our results provide no evidence for a MAP target above the current guideline recommendations that can decrease the severity of HIE.
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Affiliation(s)
- Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology and Angiology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Multmeier
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Ada Health GmbH, Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J. Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
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11
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Grand J, Wiberg S, Kjaergaard J, Hassager C, Schmidt H, Møller JE, Mølstrøm S, Granholm A. Lower versus higher blood pressure targets in comatose patients resuscitated from out-of-hospital cardiac arrest-Protocol for a secondary Bayesian analysis of the box trial. Acta Anaesthesiol Scand 2024; 68:702-707. [PMID: 38380494 DOI: 10.1111/aas.14392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND The management of blood pressure targets during intensive care after out-of-hospital cardiac arrest (OHCA) remains a topic of debate. The blood Pressure and Oxygenation Targets After OHCA (BOX) trial explored the efficacy of two different blood pressure targets in 789 patients during intensive care after OHCA. In the primary frequentist analysis, no statistically significant differences were found for neurological outcome after 90 days. METHODS This protocol outlines secondary Bayesian analyses of 365-day all-cause mortality and two secondary outcomes: neurological outcome after 365 days, and plasma neuron-specific enolase, a biomarker of brain injury, after 48 h. We will employ adjusted Bayesian logistic and linear regressions, presenting results as relative and absolute differences with 95% confidence intervals. We will use weakly informative priors for the primary analyses, and skeptical and evidence-based priors (where available) in sensitivity analyses. Exact probabilities for any benefit/harm will be presented for all outcomes, along with probabilities of clinically important benefit/harm (risk differences larger than 2%-points absolute) and no clinically important differences for the binary outcomes. We will assess whether heterogeneity of treatment effects on mortality is present according to lactate at admission, time to return of spontaneous circulation, primary shockable rhythm, age, hypertension, and presence of ST-elevation myocardial infarction. DISCUSSION This secondary analysis of the BOX trial aim to complement the primary frequentist analysis by quantifying the probabilities of beneficial or harmful effects of different blood pressure targets. This approach seeks to provide clearer insights for researchers and clinicians into the effectiveness of these blood pressure management strategies in acute medical conditions, particularly focusing on mortality, neurological outcomes, and neuron-specific enolase.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital, Hvidovre and Amager Hospital, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Denmark and Clinical Institute University of Southern Denmark, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
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12
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Skrifvars MB. How can we interpret the unexpected results in two pilot trials comparing thiamine to placebo after cardiac arrest? Resuscitation 2024; 198:110190. [PMID: 38522734 DOI: 10.1016/j.resuscitation.2024.110190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland.
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13
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van Diepen S, Le May MR, Alfaro P, Goldfarb MJ, Luk A, Mathew R, Peretz-Larochelle M, Rayner-Hartley E, Russo JJ, Senaratne JM, Ainsworth C, Belley-Côté E, Fordyce CB, Kromm J, Overgaard CB, Schnell G, Wong GC. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care. Can J Cardiol 2024; 40:524-539. [PMID: 38604702 DOI: 10.1016/j.cjca.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 04/13/2024] Open
Abstract
Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patricia Alfaro
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Maude Peretz-Larochelle
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Erin Rayner-Hartley
- Royal Columbian Hospital, Division of Cardiology, University of British Columbia, New Westminster, British Columbia, Canada
| | - Juan J Russo
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Janek M Senaratne
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Kromm
- Department of Critical Care, Department of Clinical Neurosciences, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Gregory Schnell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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14
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Heikkilä E, Setälä P, Jousi M, Nurmi J. Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care. Resusc Plus 2024; 17:100577. [PMID: 38375443 PMCID: PMC10875297 DOI: 10.1016/j.resplu.2024.100577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/14/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Aim Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (EtCO2) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA). Methods In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO2 and EtCO2 before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC). Results Mortality related to SBP and EtCO2 values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO2 shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO2 < 4.0 kPa (OR 1.4 [1.1-1.5]), respectively. SpO2 was not significantly associated with either 30-day or one year mortality. Conclusions After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO2 < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.
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Affiliation(s)
- Elina Heikkilä
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Milla Jousi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
- FinnHEMS Research and Development Unit, Finland 4
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15
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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16
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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17
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Gonzalez D, Dahiya G, Mutirangura P, Ergando T, Mello G, Singh R, Bentho O, Elliott AM. Post Cardiac Arrest Care in the Cardiac Intensive Care Unit. Curr Cardiol Rep 2024; 26:35-49. [PMID: 38214836 DOI: 10.1007/s11886-023-02015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. RECENT FINDINGS Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes.
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Affiliation(s)
- Daniel Gonzalez
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Garima Dahiya
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, USA
| | | | | | - Gregory Mello
- University of Minnesota Medical School, Minneapolis, USA
| | - Rahul Singh
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Oladi Bentho
- Department of Neurology, University of Minnesota, Minneapolis, USA
| | - Andrea M Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA.
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18
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Slovis JC, Bach A, Beaulieu F, Zuckerberg G, Topjian A, Kirschen MP. Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification. Neurocrit Care 2024; 40:99-115. [PMID: 37002474 PMCID: PMC10544744 DOI: 10.1007/s12028-023-01685-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. METHODS In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. RESULTS For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. CONCLUSION Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA.
| | - Ashley Bach
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Gabe Zuckerberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
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19
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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20
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Ushpol A, Je S, Niles D, Majmudar T, Kirschen M, Del Castillo J, Buysse C, Topjian A, Nadkarni V, Gangadharan S. Association of blood pressure with neurologic outcome at hospital discharge after pediatric cardiac arrest resuscitation. Resuscitation 2024; 194:110066. [PMID: 38056760 PMCID: PMC11024592 DOI: 10.1016/j.resuscitation.2023.110066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/27/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Poor outcomes are associated with post cardiac arrest blood pressures <5th percentile for age. We aimed to study the relationship of mean arterial pressure (MAP) with favorable neurologic outcome following cardiac arrest and return of spontaneous circulation (ROSC). METHODS This retrospective, multi-center, observational study analyzed data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q). Children (<18 years) who achieved ROSC following index in-hospital or out-of-hospital cardiac arrest and survived ≥6 hours were included. Lowest documented MAP within the first 6 hours of ROSC was percentile adjusted for age and categorized into six groups - Group I: <5th, II: 5-24th, III: 25-49th, IV: 50-74th, V: 75-94th; and VI: 95-100th percentile. Primary outcome was favorable neurologic status at hospital discharge, defined as PCPC score 1, 2, or no change from pre-arrest baseline. Multivariable logistic regression was performed to analyze the association of MAP group with favorable outcome, controlling for illness category (surgical-cardiac), initial rhythm (shockable), arrest time (weekend or overnight), age, CPR duration, and clustering by site. RESULTS 787 patients were included: median [Q1,Q3] age 17.9 [4.8,90.6] months; male 58%; OHCA 21%; shockable rhythm 13%; CPR duration 7 [3,16] min; favorable neurologic outcome 54%. Median lowest documented MAP percentile for the favorable outcome group was 13 [3,43] versus 8 [1,37] for the unfavorable group. The distribution of blood pressures by MAP group was I: 37%, II: 28%, III: 13%, IV: 11%, V: 7%, and VI: 4%. Compared with patients in Group I (<5%ile), Groups II, III, and IV had higher odds of favorable outcome (aOR, 1.84 [95% CI, 1.24, 2.73]; 2.20 [95% CI, 1.32, 3.68]; 1.90 [95% CI, 1.12, 3.25]). There was no association between Groups V or VI and favorable outcome (aOR, 1.44 [95% CI, 0.75, 2.80]; 1.11 [95% CI, 0.47, 2.59]). CONCLUSION In the first 6-hours post-ROSC, a lowest documented MAP between the 5th-74th percentile for age was associated with favorable neurologic outcome compared to MAP <5th percentile for age.
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Affiliation(s)
- A Ushpol
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA.
| | - S Je
- Departments of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - D Niles
- Departments of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - T Majmudar
- Drexel University College of Medicine, 2900 W Queen Ln, Philadelphia, PA 19129, USA
| | - M Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - J Del Castillo
- Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, C. del Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - C Buysse
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - A Topjian
- Departments of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - V Nadkarni
- Departments of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - S Gangadharan
- Department of Pediatrics, Division of Critical Care Medicine, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, 1184 5th Ave, New York, NY 10029, USA
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21
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Khan JM, Shore A, Lee KFH, Wood MD, Maslove DM, Hunt M, Georgescu I, Muscedere J, Boyd JG. Cerebral autoregulation-based mean arterial pressure targets and delirium in critically ill adults without brain injury: a retrospective cohort study. Can J Anaesth 2024; 71:107-117. [PMID: 37932650 DOI: 10.1007/s12630-023-02609-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Cerebral autoregulation (CA) is a mechanism that acts to maintain consistent cerebral perfusion across a range of blood pressures, and impaired CA is associated with delirium. Individualized CA-derived blood pressure targets are poorly characterized in critically ill patients and the association with intensive care unit (ICU) delirium is unknown. Our objectives were to characterize optimal mean arterial pressure (MAPopt) ranges in critically ill adults without brain injury and determine whether deviations from these targets contribute to ICU delirium. METHODS We performed a retrospective cohort analysis of patients with shock of any etiology and/or respiratory failure requiring invasive mechanical ventilation, without a neurologic admitting diagnosis. Patients were screened daily for delirium. Cerebral oximetry and mean arterial pressure data were captured for the first 24 hr from enrolment. RESULTS Forty-two patients with invasive blood pressure monitoring data were analyzed. Optimal mean arterial pressure targets ranged from 55 to 100 mm Hg. Optimal mean arterial pressure values were not significantly different based on history of hypertension or delirium status, and delirium was not associated with deviations from MAPopt. Nevertheless, the majority (69%) of blood pressure targets exceeded the current 65 mm Hg Surviving Sepsis guidelines. CONCLUSION We observed that MAPopt targets across patients were highly variable, but did not observe an association with the incidence of delirium. Studies designed to evaluate the impact on neurologic outcomes are needed to understand the association with individualized mean arterial pressure targets in the ICU. STUDY REGISTRATION ClinicalTrials.gov (NCT02344043); first submitted 22 January 2015.
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Affiliation(s)
- Jasmine M Khan
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Abigail Shore
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Kevin F H Lee
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michael D Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - David M Maslove
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Miranda Hunt
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Ilinca Georgescu
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - J Gordon Boyd
- Department of Medicine, Queen's University, Kingston, ON, Canada.
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
- Kingston General Hospital, Davies 2, 76 Stuart St., Kingston, ON, K7L 2V7, Canada.
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22
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Grand J, Møller JE, Hassager C, Schmidt H, Mølstrøm S, Boesgaard S, Meyer MAS, Josiassen J, Højgaard HF, Frydland M, Dahl JS, Obling LER, Bak M, Lind Jørgensen V, Thomsen JH, Wiberg S, Madsen SA, Nyholm B, Kjaergaard J. Impact of blood pressure targets on central hemodynamics during intensive care after out-of-hospital cardiac arrest. Resuscitation 2024; 194:110094. [PMID: 38103857 DOI: 10.1016/j.resuscitation.2023.110094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES The aim was to investigate the advanced hemodynamic effects of the two MAP-targets during intensive care on systemic hemodynamics in comatose patients after cardiac arrest. DESIGN Secondary analysis of a randomized controlled trial. SETTING Primary vasopressor used was per protocol norepinephrine. Hemodynamic monitoring was done with pulmonary artery catheters (PAC) and measurements were made on predefined time points. The primary endpoint of this substudy was the difference in cardiac index within 48 h from a repeated measurements-mixed model. Secondary endpoints included systemic vascular resistance index (SVRI), heart rate, and stroke volume index. PATIENTS Comatose survivors after out-of-hospital cardiac arrest. INTERVENTIONS The "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial was a randomized, controlled, double-blinded, multicenter-study comparing targeted mean arterial pressure (MAP) of 63 mmHg (MAP63) vs 77 mmHg (MAP77). MEASUREMENTS AND MAIN RESULTS Among 789 randomized patients, 730 (93%) patients were included in the hemodynamic substudy. From PAC-insertion (median 1 hours after ICU-admission) and the next 48 hours, the MAP77-group received significantly higher doses of norepinephrine (mean difference 0.09 µg/kg/min, 95% confidence interval (CI) 0.07-0.11, pgroup < 0.0001). Cardiac index was significantly increased (0.20 L/min/m2 (CI 0.12-0.28), pgroup < 0.0001) as was SVRI with an overall difference of (43 dynes m2/s/cm5 (CI 7-79); pgroup = 0.02). Heart rate was increased in the MAP77-group (4 beats/minute; CI 2-6, pgroup < 0.003), but stroke volume index was not (pgroup = 0.10). CONCLUSIONS Targeted MAP at 77 mmHg compared to 63 mmHg resulted in a higher dose of norepinephrine, increased cardiac index and SVRI. Heart rate was also increased, but stroke volume index was not affected by a higher blood pressure target.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital, Amager-Hvidovre, Copenhagen, Denmark.
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark; Clinical Institute University of Southern Denmark, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Simon Mølstrøm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Søren Boesgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Martin Frydland
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark; Clinical Institute University of Southern Denmark, Denmark
| | | | - Mikkel Bak
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Hartvig Thomsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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23
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Abuelazm M, Ali S, Mahmoud A, Mechi A, Kadhim H, Katamesh BE, Elzeftawy MA, Ibrahim AA, Abdelazeem B. High versus low mean arterial pressure targets after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2023; 78:154365. [PMID: 37516092 DOI: 10.1016/j.jcrc.2023.154365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Targeting a specific mean arterial pressure (MAP) has been evaluated as a treatment strategy after out-of-hospital cardiac arrest (OHCA) resuscitation. However, the current evidence lacks clear guidelines regarding the optimal MAP target after OHCA. METHODS A systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), retrieved by systematically searching: PubMed, EMBASE, WOS, SCOPUS, and Cochrane through January 18th, 2023. Our review protocol was prospectively published on PROSPERO with ID: CRD42023395333. RESULTS Four RCTs with a total of 1065 patients were included in our analysis. There was no difference between high MAP versus low MAP regarding the primary outcomes: all-cause mortality (RR: 1.07 with a 95% CI [0.91, 1.27], P = 0.4) and favorable neurological recovery (RR: 1.02 with a 95% CI [0.93, 1.13], P = 0.68). However, high MAP target was significantly associated with decreased ICU stay duration (MD: -0.78 with a 95 CI [-1.54, -0.02], P = 0.04) and mechanical ventilation duration (MD: -0.91 with a 95 CI of [-1.51, -0.31], P = 0.003). CONCLUSION A high MAP target may reduce ICU stay and mechanical ventilation duration but did not demonstrate improvements in either mortality or favorable neurological recovery. Therefore, the role of high MAP target remains uncertain and requires further RCTs.
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Affiliation(s)
| | - Shafaqat Ali
- Department of Internal Medicine, Louisiana State University, Shreveport, LA, USA
| | | | - Ahmed Mechi
- Department of Internal Medicine, Medicine College, University of Kufa, Najaf, Iraq
| | - Hallas Kadhim
- Department of Internal Medicine, University of Al Muthanna, Al Muthanna, Iraq
| | - Basant E Katamesh
- Faculty of Medicine, Tanta University, Tanta, Egypt; General internal medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
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24
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Behringer W, Skrifvars MB, Taccone FS. Postresuscitation management. Curr Opin Crit Care 2023; 29:640-647. [PMID: 37909369 DOI: 10.1097/mcc.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. RECENT FINDINGS Targeting a lower oxygen target (90-94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32-34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. SUMMARY Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32-34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.
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Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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25
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Laurikkala J, Ameloot K, Reinikainen M, Palmers PJ, De Deyne C, Bert F, Dupont M, Janssens S, Dens J, Hästbacka J, Jakkula P, Loisa P, Birkelund T, Wilkman E, Vaara ST, Skrifvars MB. The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials. Ann Intensive Care 2023; 13:113. [PMID: 37987871 PMCID: PMC10663425 DOI: 10.1186/s13613-023-01210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. METHODS A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. RESULTS A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). CONCLUSION Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. CLINICAL TRIAL REGISTRATION COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).
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Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland.
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ferdinande Bert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Suvi T Vaara
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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26
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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27
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Shen Y. Analysis of static parameters in retrospective studies: limitations and interpretation. Crit Care 2023; 27:404. [PMID: 37872549 PMCID: PMC10594905 DOI: 10.1186/s13054-023-04691-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023] Open
Affiliation(s)
- Yanfei Shen
- Department of Intensive Care, Zhejiang Hospital, 1229 Gudun Road, Hangzhou, 310013, Zhejiang, China.
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28
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Thiara S, Sekhon MS. Blood pressure augmentation after cardiac arrest: Time to move beyond manipulating vital signs. Resuscitation 2023; 190:109913. [PMID: 37516157 DOI: 10.1016/j.resuscitation.2023.109913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Sharanjit Thiara
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada; International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada; Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.
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29
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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30
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Hoiland RL, Robba C, Menon DK, Citerio G, Sandroni C, Sekhon MS. Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest. Intensive Care Med 2023; 49:1062-1078. [PMID: 37507572 PMCID: PMC10499700 DOI: 10.1007/s00134-023-07165-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
The cerebral oxygen cascade includes three key stages: (a) convective oxygen delivery representing the bulk flow of oxygen to the cerebral vascular bed; (b) diffusion of oxygen from the blood into brain tissue; and (c) cellular utilisation of oxygen for aerobic metabolism. All three stages may become dysfunctional after resuscitation from cardiac arrest and contribute to hypoxic-ischaemic brain injury (HIBI). Improving convective cerebral oxygen delivery by optimising cerebral blood flow has been widely investigated as a strategy to mitigate HIBI. However, clinical trials aimed at optimising convective oxygen delivery have yielded neutral results. Advances in the understanding of HIBI pathophysiology suggest that impairments in the stages of the oxygen cascade pertaining to oxygen diffusion and cellular utilisation of oxygen should also be considered in identifying therapeutic strategies for the clinical management of HIBI patients. Culprit mechanisms for these impairments may include a widening of the diffusion barrier due to peri-vascular oedema and mitochondrial dysfunction. An integrated approach encompassing both intra-parenchymal and non-invasive neuromonitoring techniques may aid in detecting pathophysiologic changes in the oxygen cascade and enable patient-specific management aimed at reducing the severity of HIBI.
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Affiliation(s)
- Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada.
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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31
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Sekhon MS, Stukas S, Hirsch-Reinshagen V, Thiara S, Schoenthal T, Tymko M, McNagny KM, Wellington C, Hoiland R. Neuroinflammation and the immune system in hypoxic ischaemic brain injury pathophysiology after cardiac arrest. J Physiol 2023. [PMID: 37639379 DOI: 10.1113/jp284588] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Hypoxic ischaemic brain injury after resuscitation from cardiac arrest is associated with dismal clinical outcomes. To date, most clinical interventions have been geared towards the restoration of cerebral oxygen delivery after resuscitation; however, outcomes in clinical trials are disappointing. Therefore, alternative disease mechanism(s) are likely to be at play, of which the response of the innate immune system to sterile injured tissue in vivo after reperfusion has garnered significant interest. The innate immune system is composed of three pillars: (i) cytokines and signalling molecules; (ii) leucocyte migration and activation; and (iii) the complement cascade. In animal models of hypoxic ischaemic brain injury, pro-inflammatory cytokines are central to propagation of the response of the innate immune system to cerebral ischaemia-reperfusion. In particular, interleukin-1 beta and downstream signalling can result in direct neural injury that culminates in cell death, termed pyroptosis. Leucocyte chemotaxis and activation are central to the in vivo response to cerebral ischaemia-reperfusion. Both parenchymal microglial activation and possible infiltration of peripherally circulating monocytes might account for exacerbation of an immunopathological response in humans. Finally, activation of the complement cascade intersects with multiple aspects of the innate immune response by facilitating leucocyte activation, further cytokine release and endothelial activation. To date, large studies of immunomodulatory therapies have not been conducted; however, lessons learned from historical studies using therapeutic hypothermia in humans suggest that quelling an immunopathological response might be efficacious. Future work should delineate the precise pathways involved in vivo in humans to target specific signalling molecules.
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Veronica Hirsch-Reinshagen
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Michael Tymko
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Kelly M McNagny
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Biomedical Research Centre, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
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Grand J, Hassager C. State of the art post-cardiac arrest care: evolution and future of post cardiac arrest care. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:559-570. [PMID: 37329248 DOI: 10.1093/ehjacc/zuad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/18/2023]
Abstract
Out-of-hospital cardiac arrest is a leading cause of mortality. In the pre-hospital setting, bystander response with cardiopulmonary resuscitation and the use of publicly available automated external defibrillators have been associated with improved survival. Early in-hospital treatment still focuses on emergency coronary angiography for selected patients. For patients remaining comatose, temperature control to avoid fever is still recommended, but former hypothermic targets have been abandoned. For patients without spontaneous awakening, the use of a multimodal prognostication model is key. After discharge, follow-up with screening for cognitive and emotional disabilities is recommended. There has been an incredible evolution of research on cardiac arrest. Two decades ago, the largest trials include a few hundred patients. Today, undergoing studies are planning to include 10-20 times as many patients, with improved methodology. This article describes the evolution and perspectives for the future in post-cardiac arrest care.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet. Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet. Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kjaergaard J, Møller JE. Haemodynamic, oxygenation, and ventilation targets after cardiac arrest: the current ABC of post-cardiac arrest intensive care. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:513-517. [PMID: 37459572 DOI: 10.1093/ehjacc/zuad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Department of Cardiology, Odense University Hospital, JB Winsløvvej 4, Odense 5000, Denmark
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Singh A, Jefferson J. Post-Cardiac Arrest Care. Emerg Med Clin North Am 2023; 41:617-632. [PMID: 37391254 DOI: 10.1016/j.emc.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.
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Affiliation(s)
- Amandeep Singh
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Jamal Jefferson
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA
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Skrifvars MB, Ameloot K, Åneman A. Blood pressure targets and management during post-cardiac arrest care. Resuscitation 2023; 189:109886. [PMID: 37380065 DOI: 10.1016/j.resuscitation.2023.109886] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Abstract
Blood pressure is one modifiable physiological target in patients treated in the intensive care unit after cardiac arrest. Current Guidelines recommend targeting a mean arterial pressure (MAP) of higher than 65-70 mmHg using fluid resuscitation and the use of vasopressors. Management strategies will vary based in the setting, i.e. the pre-hospital compared to the in-hospital phase. Epidemiological data suggest that some degree of hypotension requiring vasopressors occur in almost 50% of patients. A higher MAP could theoretically increase coronary blood flow but on the other hand the use of vasopressor may result in an increase in cardiac oxygen demand and arrhythmia. An adequate MAP is paramount for maintaining cerebral blood flow. In some cardiac arrest patients the cerebral autoregulation may be disturbed resulting in the need for higher MAP in order to avoid decreasing cerebral blood flow. Thus far, four studies including little more than 1000 patients have compared a lower and higher MAP target in cardiac arrest patients. The achieved mean difference of MAP between groups has varied from 10-15 mmHg. Based on these studies a Bayesian meta-analysis suggests that the posterior probability that a future study would find treatment effects higher than a 5% difference between groups to be less than 50%. On the other hand, this analysis also suggests, that the likelihood of harm with a higher MAP target is also low. Noteworthy is that all studies to date have focused mainly on patients with a cardiac cause of the arrest with the majority of patients being resuscitated from a shockable initial rhythm. Future studies should aim to include also non-cardiac causes and aim to target a wider separation in MAP between groups.
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Affiliation(s)
- Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland, Meilahden Sairaala, Haartmaninkatu 9, 00029 HUS, Finland.
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Anders Åneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Australia; Faculty of Medicine and Health Sciences, Macquarie University, Australia
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Lim SL, Low CJW, Ling RR, Sultana R, Yang V, Ong MEH, Chia YW, Sharma VK, Ramanathan K. Blood Pressure Targets for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:4497. [PMID: 37445530 DOI: 10.3390/jcm12134497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND With ideal mean arterial pressure (MAP) targets in resuscitated out-of-hospital cardiac arrest (OHCA) patients unknown, we performed a meta-analysis of randomised controlled trials (RCTs) to compare the effects of higher versus lower MAP targets. METHODS We searched four databases until 1 May 2023 for RCTs reporting the effects of higher MAP targets (>70 mmHg) in resuscitated OHCA patients and conducted random-effects meta-analyses. The primary outcome was mortality while secondary outcomes were neurological evaluations, arrhythmias, acute kidney injury, and durations of mechanical ventilation and ICU stay. We conducted inverse-variance weighted strata-level meta-regression against a proportion of non-survivors to assess differences between reported MAPs. We also conducted a trial sequential analysis of RCTs. RESULTS Four RCTs were included. Higher MAP was not associated with reduced mortality (OR: 1.09, 95%-CI: 0.84 to 1.42, p = 0.51), or improved neurological outcomes (OR: 0.99, 95%-CI: 0.77 to 1.27, p = 0.92). Such findings were consistent despite additional sensitivity analyses. Our robust variance strata-level meta-regression revealed no significant associations between mean MAP and the proportion of non-survivors (B: 0.029, 95%-CI: -0.023 to 0.081, p = 0.162), and trial sequential analysis revealed no meaningful survival benefit for higher MAPs. CONCLUSIONS A higher MAP target was not significantly associated with improved mortality and neurological outcomes in resuscitated OHCA patients.
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Affiliation(s)
- Shir Lynn Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Pre-Hospital Emergency Research Center, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Victoria Yang
- Imperial College Healthcare NHS Trust, London W12 OHS, UK
| | - Marcus E H Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Yew Woon Chia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 639798, Singapore
| | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, National University Health System, Singapore 119074, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre Singapore, Singapore 119074, Singapore
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Cheema HA, Shafiee A, Athar MMT, Akhondi A, Shahid A, Ghafoor MS, Yasmin F, Nashwan AJ, Titus A. Higher versus lower blood pressure targets after cardiac arrest: A meta-analysis of randomized controlled trials. Indian Heart J 2023; 75:304-307. [PMID: 37328138 PMCID: PMC10421983 DOI: 10.1016/j.ihj.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/12/2023] [Indexed: 06/18/2023] Open
Abstract
A few mostly underpowered randomized controlled trials (RCTs) have been used to study the impact of blood pressure (BP) targets in out-of-hospital cardiac arrest (OHCA) patients. We aimed to perform an updated meta-analysis to compare the outcomes between the higher BP target and the lower BP target groups following OHCA. A systematic search was conducted on PubMed, Embase and the Cochrane Library until December 2022. We pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) using RevMan 5.4. Our search yielded four RCTs with a total of 1114 patients. Regarding our primary outcome of all-cause mortality, there was no significant difference between higher versus lower BP target goals in post-OHCA patients (OR 1.12, 95% CI: 0.86 to 1.45). Furthermore, there were no significant differences between the two groups in good neurological outcome, the incidence of arrhythmia, need for renal replacement therapy, and the levels of neuron-specific enolase at 48 h. The length of ICU stay of patients treated with the higher BP target was significantly lower but by a small margin. These findings do not support the use of a higher BP target but are subject to confirmation by large-scale RCTs investigating homogenous BP goals.
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Affiliation(s)
| | - Arman Shafiee
- Clinical Research Development Unit, Alborz University of Medical Sciences, Karaj, Iran; Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Amirhossein Akhondi
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Abia Shahid
- Department of Cardiology, King Edward Medical University, Lahore, Pakistan
| | | | - Farah Yasmin
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Anoop Titus
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA, USA
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Rikhraj KJK, Ronsley C, Sekhon MS, Mitra AR, Griesdale DEG. High-normal versus low-normal mean arterial pressure thresholds in critically ill patients: a systematic review and meta-analysis of randomized trials. Can J Anaesth 2023; 70:1244-1254. [PMID: 37268800 DOI: 10.1007/s12630-023-02494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE Targeted blood pressure thresholds remain unclear in critically ill patients. Two prior systematic reviews have not shown differences in mortality with a high mean arterial pressure (MAP) threshold, but there have been new studies published since. Thus, we conducted an updated systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effect of a high-normal vs low-normal MAP on mortality, favourable neurologic outcome, need for renal replacement therapy, and adverse vasopressor-induced events in critically ill patients. SOURCE We searched six databases from inception until 1 October 2022 for RCTs of critically ill patients targeted to either a high-normal vs a low-normal MAP threshold for at least 24 hr. We assessed study quality using the revised Cochrane risk-of-bias 2 tool and the risk ratio (RR) was used as the summary measure of association. We used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence. PRINCIPAL FINDINGS We included eight RCTs with 4,561 patients. Four trials were conducted in patients following out-of-hospital cardiac arrest, two in patients with distributive shock requiring vasopressors, one in patients with septic shock, and one in patients with hepatorenal syndrome. The pooled RRs for mortality (eight RCTs; 4,439 patients) and favourable neurologic outcome (four RCTs; 1,065 patients) were 1.06 (95% confidence interval [CI], 0.99 to 1.14; moderate certainty) and 0.99 (95% CI, 0.90 to 1.08; moderate certainty), respectively. The RR for the need for renal replacement therapy (four RCTs; 4,071 patients) was 0.97 (95% CI, 0.87 to 1.08; moderate certainty). There was no statistical between-study heterogeneity across all outcomes. CONCLUSION This updated systematic review and meta-analysis of RCTs found no differences in mortality, favourable neurologic outcome, or the need for renal replacement therapy between critically ill patients assigned to a high-normal vs low-normal MAP target. STUDY REGISTRATION PROSPERO (CRD42022307601); registered 28 February 2022.
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Affiliation(s)
- Kiran J K Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.
- Department of Emergency Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Claire Ronsley
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Binois Y, Renaudier M, Dumas F, Youssfi Y, Beganton F, Jost D, Lamhaut L, Marijon E, Jouven X, Cariou A, Bougouin W. Factors associated with circulatory death after out-of-hospital cardiac arrest: a population-based cluster analysis. Ann Intensive Care 2023; 13:49. [PMID: 37294400 DOI: 10.1186/s13613-023-01143-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a common cause of death. Early circulatory failure is the most common reason for death within the first 48 h. This study in intensive care unit (ICU) patients with OHCA was designed to identify and characterize clusters based on clinical features and to determine the frequency of death from refractory postresuscitation shock (RPRS) in each cluster. METHODS We retrospectively identified adults admitted alive to ICUs after OHCA in 2011-2018 and recorded in a prospective registry for the Paris region (France). We identified patient clusters by performing an unsupervised hierarchical cluster analysis (without mode of death among the variables) based on Utstein clinical and laboratory variables. For each cluster, we estimated the hazard ratio (HRs) for RPRS. RESULTS Of the 4445 included patients, 1468 (33%) were discharged alive from the ICU and 2977 (67%) died in the ICU. We identified four clusters: initial shockable rhythm with short low-flow time (cluster 1), initial non-shockable rhythm with usual absence of ST-segment elevation (cluster 2), initial non-shockable rhythm with long no-flow time (cluster 3), and long low-flow time with high epinephrine dose (cluster 4). RPRS was significantly associated with this last cluster (HR, 5.51; 95% confidence interval 4.51-6.74). CONCLUSIONS We identified patient clusters based on Utstein criteria, and one cluster was strongly associated with RPRS. This result may help to make decisions about using specific treatments after OHCA.
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Affiliation(s)
- Yannick Binois
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Marie Renaudier
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Florence Dumas
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Emergency Department, AP-HP, Cochin-Hotel-Dieu Hospital, 75014, Paris, France
| | - Younès Youssfi
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Center for Research in Economics and Statistics, 91120, Palaiseau, France
| | - Frankie Beganton
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Daniel Jost
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- BSPP (Paris Fire-Brigade Emergency-Medicine Department), 1 Place Jules Renard, 75017, Paris, France
| | - Lionel Lamhaut
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, 75014, Paris, France
| | - Eloi Marijon
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Xavier Jouven
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Alain Cariou
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, 75014, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- AfterROSC network, Paris, France
| | - Wulfran Bougouin
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France.
- Paris Sudden Death Expertise Center, 75015, Paris, France.
- Medical Intensive Care Unit, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300, Massy, France.
- AfterROSC network, Paris, France.
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Niemelä V, Siddiqui F, Ameloot K, Reinikainen M, Grand J, Hästbacka J, Hassager C, Kjaergard J, Åneman A, Tiainen M, Nielsen N, Harboe Olsen M, Kamp Jorgensen C, Juul Petersen J, Dankiewicz J, Saxena M, Jakobsen JC, Skrifvars MB. Higher versus lower blood pressure targets after cardiac arrest: systematic review with individual patient data meta-analysis. Resuscitation 2023:109862. [PMID: 37295549 DOI: 10.1016/j.resuscitation.2023.109862] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Guidelines recommend targeting mean arterial pressure (MAP) > 65 mmHg in patients after cardiac arrest (CA). Recent trials have studied the effects of targeting a higher MAP as compared to a lower MAP after CA. We performed a systematic review and individual patient data meta-analysis to investigate the effects of higher versus lower MAP targets on patient outcome. METHOD We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus, the Web of Science Core Collection, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, Google Scholar and the Turning Research into Practice database to identify trials randomizing patients to higher (≥ 71 mmHg) or lower (≤70 mmHg) MAP targets after CA and resuscitation. We used the Cochrane Risk of Bias tool, version 2 (RoB 2) to assess for risk of bias. The primary outcomes were 180-day all-cause mortality and poor neurologic recovery defined by a modified Rankin score of 4-6 or a cerebral performance category score of 3-5. RESULTS Four eligible clinical trials were identified, randomizing a total of 1,087 patients. All the included trials were assessed as having a low risk for bias. The risk ratio (RR) with 95% confidence interval for 180-day all-cause mortality for a higher versus a lower MAP target was 1.08 (0.92-1.26) and for poor neurologic recovery 1.01 (0.86-1.19). Trial sequential analysis showed that a 25% or higher treatment effect, i.e., RR<0.75, can be excluded. No difference in serious adverse events was found between the higher and lower MAP groups. CONCLUSIONS Targeting a higher MAP compared to a lower MAP is unlikely to reduce mortality or improve neurologic recovery after CA. Only a large treatment effect above 25% (RR<0.75) could be excluded, and future studies are needed to investigate if relevant but lower treatment effect exists. Targeting a higher MAP was not associated with any increase in adverse effects.
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Affiliation(s)
- Ville Niemelä
- Department of Anaesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Johannes Grand
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Johanna Hästbacka
- Department of Anaesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergard
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Åneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, South Western Clinical School, University of New South Wales, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Niklas Nielsen
- Lund University and Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund, Sweden; Skåne University Hospital, Clinical Studies Sweden - Forum South, Lund, Sweden; Anaesthesia and Intensive Care, Helsingborg Hospital, Lund, Sweden
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Caroline Kamp Jorgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Johanne Juul Petersen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Manoj Saxena
- South Western Clinical School, University of New South Wales, Sydney, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
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Wudwud A, Hendin A, Perry J. Does targeting a higher versus lower MAP improve survival following out-of-hospital cardiac arrest? CAN J EMERG MED 2023; 25:376-377. [PMID: 37087713 DOI: 10.1007/s43678-023-00501-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/24/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Alie Wudwud
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Ariel Hendin
- Department of Emergency Medicine; Department of Critical Care, Hôpital Montfort, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jeffrey Perry
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Penna A, Magliocca A, Merigo G, Stirparo G, Silvestri I, Fumagalli F, Ristagno G. One-Year Review in Cardiac Arrest: The 2022 Randomized Controlled Trials. J Clin Med 2023; 12:jcm12062235. [PMID: 36983236 PMCID: PMC10054058 DOI: 10.3390/jcm12062235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Cardiac arrest, one of the leading causes of death, accounts for numerous clinical studies published each year. This review summarizes the findings of all the randomized controlled clinical trials (RCT) on cardiac arrest published in the year 2022. The RCTs are presented according to the following categories: out-of- and in-hospital cardiac arrest (OHCA, IHCA) and post-cardiac arrest care. Interestingly, more than 80% of the RCTs encompassed advanced life support and post-cardiac arrest care, while no studies focused on the treatment of IHCA, except for one that, however, explored the temperature control after resuscitation in this population. Surprisingly, 9 out of 11 RCTs led to neutral results demonstrating equivalency between the newly tested interventions compared to current practice. One trial was negative, showing that oxygen titration in the immediate pre-hospital post-resuscitation period decreased survival compared to a more liberal approach. One RCT was positive and introduced new defibrillation strategies for refractory cardiac arrest. Overall, data from the 2022 RCTs discussed here provide a solid basis to generate new hypotheses to be tested in future clinical studies.
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Affiliation(s)
- Alessio Penna
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Mario Negri Institute for Pharmacological Researches IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Giulia Merigo
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Giuseppe Stirparo
- Agenzia Regionale Emergenza Urgenza (AREU), Via Campanini 6, 20124 Milan, Italy
| | - Ivan Silvestri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Francesca Fumagalli
- Mario Negri Institute for Pharmacological Researches IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
- Correspondence:
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Mølstrøm S, Nielsen TH, Nordstrøm CH, Forsse A, Møller S, Venø S, Mamaev D, Tencer T, Theódórsdóttir Á, Krøigård T, Møller J, Hassager C, Kjærgaard J, Schmidt H, Toft P. A randomized, double-blind trial comparing the effect of two blood pressure targets on global brain metabolism after out-of-hospital cardiac arrest. Crit Care 2023; 27:73. [PMID: 36823636 PMCID: PMC9951410 DOI: 10.1186/s13054-023-04376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to assess the effect of different blood pressure levels on global cerebral metabolism in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In a double-blinded trial, we randomly assigned 60 comatose patients following OHCA to low (63 mmHg) or high (77 mmHg) mean arterial blood pressure (MAP). The trial was a sub-study in the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Global cerebral metabolism utilizing jugular bulb microdialysis (JBM) and cerebral oxygenation (rSO2) was monitored continuously for 96 h. The lactate-to-pyruvate (LP) ratio is a marker of cellular redox status and increases during deficient oxygen delivery (ischemia, hypoxia) and mitochondrial dysfunction. The primary outcome was to compare time-averaged means of cerebral energy metabolites between MAP groups during post-resuscitation care. Secondary outcomes included metabolic patterns of cerebral ischemia, rSO2, plasma neuron-specific enolase level at 48 h and neurological outcome at hospital discharge (cerebral performance category). RESULTS We found a clear separation in MAP between the groups (15 mmHg, p < 0.001). Cerebral biochemical variables were not significantly different between MAP groups (LPR low MAP 19 (16-31) vs. high MAP 23 (16-33), p = 0.64). However, the LP ratio remained high (> 16) in both groups during the first 30 h. During the first 24 h, cerebral lactate > 2.5 mM, pyruvate levels > 110 µM, LP ratio > 30, and glycerol > 260 µM were highly predictive for poor neurological outcome and death with AUC 0.80. The median (IQR) rSO2 during the first 48 h was 69.5% (62.0-75.0%) in the low MAP group and 69.0% (61.3-75.5%) in the high MAP group, p = 0.16. CONCLUSIONS Among comatose patients resuscitated from OHCA, targeting a higher MAP 180 min after ROSC did not significantly improve cerebral energy metabolism within 96 h of post-resuscitation care. Patients with a poor clinical outcome exhibited significantly worse biochemical patterns, probably illustrating that insufficient tissue oxygenation and recirculation during the initial hours after ROSC were essential factors determining neurological outcome.
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Affiliation(s)
- Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Troels Halfeld Nielsen
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Carl-Henrik Nordstrøm
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- grid.4973.90000 0004 0646 7373Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Møller
- grid.7143.10000 0004 0512 5013OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Venø
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Dmitry Mamaev
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Tomas Tencer
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ásta Theódórsdóttir
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jacob Møller
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark ,grid.7143.10000 0004 0512 5013Department of Cardiology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Medicine, University of Southern, Odense, Denmark
| | - Christian Hassager
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjærgaard
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Palle Toft
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
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45
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Chudeau N, Guitton C, Cariou A. Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2023; 388:285-286. [PMID: 36652368 DOI: 10.1056/nejmc2215179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Alain Cariou
- Assistance Publique-Hôpitaux de Paris Centre Université Paris Cité, Paris, France
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McGuigan PJ, Giallongo E, Blackwood B, Doidge J, Harrison DA, Nichol AD, Rowan KM, Shankar-Hari M, Skrifvars MB, Thomas K, McAuley DF. The effect of blood pressure on mortality following out-of-hospital cardiac arrest: a retrospective cohort study of the United Kingdom Intensive Care National Audit and Research Centre database. Crit Care 2023; 27:4. [PMID: 36604745 PMCID: PMC9817239 DOI: 10.1186/s13054-022-04289-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypotension following out-of-hospital cardiac arrest (OHCA) may cause secondary brain injury and increase mortality rates. Current guidelines recommend avoiding hypotension. However, the optimal blood pressure following OHCA is unknown. We hypothesised that exposure to hypotension and hypertension in the first 24 h in ICU would be associated with mortality following OHCA. METHODS We conducted a retrospective analysis of OHCA patients included in the Intensive Care National Audit and Research Centre Case Mix Programme from 1 January 2010 to 31 December 2019. Restricted cubic splines were created following adjustment for important prognostic variables. We report the adjusted odds ratio for associations between lowest and highest mean arterial pressure (MAP) and systolic blood pressure (SBP) in the first 24 h of ICU care and hospital mortality. RESULTS A total of 32,349 patients were included in the analysis. Hospital mortality was 56.2%. The median lowest and highest MAP and SBP were similar in survivors and non-survivors. Both hypotension and hypertension were associated with increased mortality. Patients who had a lowest recorded MAP in the range 60-63 mmHg had the lowest associated mortality. Patients who had a highest recorded MAP in the range 95-104 mmHg had the lowest associated mortality. The association between SBP and mortality followed a similar pattern to MAP. CONCLUSIONS We found an association between hypotension and hypertension in the first 24 h in ICU and mortality following OHCA. The inability to distinguish between the median blood pressure of survivors and non-survivors indicates the need for research into individualised blood pressure targets for survivors following OHCA.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK.
| | - Elisa Giallongo
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Karen Thomas
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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48
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Abdulmajeed F, Hamandi M, Malaiyandi D, Shutter L. Neurocritical Care in the General Intensive Care Unit. Crit Care Clin 2023; 39:153-169. [DOI: 10.1016/j.ccc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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49
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Cassara CM, Long MT, Dollerschell JT, Chae F, Hall DJ, Demiralp G, Stampfl MJ, Bernardoni B, McCarthy DP, Glazer JM. Extracorporeal Cardiopulmonary Resuscitation: A Narrative Review and Establishment of a Sustainable Program. Medicina (B Aires) 2022; 58:medicina58121815. [PMID: 36557017 PMCID: PMC9781756 DOI: 10.3390/medicina58121815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The rates of survival with functional recovery for out of hospital cardiac arrest remain unacceptably low. Extracorporeal cardiopulmonary resuscitation (ECPR) quickly resolves the low-flow state of conventional cardiopulmonary resuscitation (CCPR) providing valuable perfusion to end organs. Observational studies have shown an association with the use of ECPR and improved survivability. Two recent randomized controlled studies have demonstrated improved survival with functional neurologic recovery when compared to CCPR. Substantial resources and coordination amongst different specialties and departments are crucial for the successful implementation of ECPR. Standardized protocols, simulation based training, and constant communication are invaluable to the sustainability of a program. Currently there is no standardized protocol for the post-cannulation management of these ECPR patients and, ideally, upcoming studies should aim to evaluate these protocols.
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Affiliation(s)
- Chris M. Cassara
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-8100
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - John T. Dollerschell
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Floria Chae
- Department of Anesthesiology, Ohio State University Wexner Medical Center, 370 W. 9th Ave., Columbus, OH 43210, USA
| | - David J. Hall
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Matthew J. Stampfl
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Brittney Bernardoni
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Daniel P. McCarthy
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Joshua M. Glazer
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
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50
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Kjaergaard J, Møller JE, Schmidt H, Grand J, Mølstrøm S, Borregaard B, Venø S, Sarkisian L, Mamaev D, Jensen LO, Nyholm B, Høfsten DE, Josiassen J, Thomsen JH, Thune JJ, Obling LER, Lindholm MG, Frydland M, Meyer MAS, Winther-Jensen M, Beske RP, Frikke-Schmidt R, Wiberg S, Boesgaard S, Madsen SA, Jørgensen VL, Hassager C. Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2022; 387:1456-1466. [PMID: 36027564 DOI: 10.1056/nejmoa2208687] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence to support the choice of blood-pressure targets for the treatment of comatose survivors of out-of-hospital cardiac arrest who are receiving intensive care is limited. METHODS In a double-blind, randomized trial with a 2-by-2 factorial design, we evaluated a mean arterial blood-pressure target of 63 mm Hg as compared with 77 mm Hg in comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause; patients were also assigned to one of two oxygen targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category (CPC) of 3 or 4 within 90 days (range, 0 to 5, with higher categories indicating more severe disability; a category of 3 or 4 indicates severe disability or coma). Secondary outcomes included neuron-specific enolase levels at 48 hours, death from any cause, scores on the Montreal Cognitive Assessment (range, 0 to 30, with higher scores indicating better cognitive ability) and the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 3 months, and the CPC at 3 months. RESULTS A total of 789 patients were included in the analysis (393 in the high-target group and 396 in the low-target group). A primary-outcome event occurred in 133 patients (34%) in the high-target group and in 127 patients (32%) in the low-target group (hazard ratio, 1.08; 95% confidence interval [CI], 0.84 to 1.37; P = 0.56). At 90 days, 122 patients (31%) in the high-target group and 114 patients (29%) in the low-target group had died (hazard ratio, 1.13; 95% CI, 0.88 to 1.46). The median CPC was 1 (interquartile range, 1 to 5) in both the high-target group and the low-target group; the corresponding median modified Rankin scale scores were 1 (interquartile range, 0 to 6) and 1 (interquartile range, 0 to 6), and the corresponding median Montreal Cognitive Assessment scores were 27 (interquartile range, 24 to 29) and 26 (interquartile range, 24 to 29). The median neuron-specific enolase level at 48 hours was also similar in the two groups. The percentages of patients with adverse events did not differ significantly between the groups. CONCLUSIONS Targeting a mean arterial blood pressure of 77 mm Hg or 63 mm Hg in patients who had been resuscitated from cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
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Affiliation(s)
- Jesper Kjaergaard
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jacob E Møller
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Henrik Schmidt
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Johannes Grand
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Britt Borregaard
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Søren Venø
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Laura Sarkisian
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Dmitry Mamaev
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Lisette O Jensen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Benjamin Nyholm
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Dan E Høfsten
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jakob Josiassen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jens J Thune
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Laust E R Obling
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Matias G Lindholm
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Martin Frydland
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Martin A S Meyer
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Rasmus P Beske
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Ruth Frikke-Schmidt
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Sebastian Wiberg
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Søren Boesgaard
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Søren A Madsen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Vibeke L Jørgensen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Christian Hassager
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
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