Association of extracerebral organ failure with 1-year survival and healthcare-associated costs after cardiac arrest: an observational database study

The detrimental effects of intestinal injury mediated by inflammation are limited in cardiac arrest patients: A prospective cohort study

Background

Ischaemic intestines could be a driver of critical illness through an inflammatory response. We have previously published reports on a biomarker for intestinal injury, plasma Intestinal Fatty Acid Binding Protein (IFABP), and inflammatory biomarkers after out-of-hospital cardiac arrest (OHCA). In this post-hoc study we explored the potential indirect effects of intestinal injury mediated through the inflammatory response on organ dysfunction and mortality.

Methods

We measured IFABP and twenty-one inflammatory biomarkers in 50 patients at admission to intensive care unit after OHCA. First, we stratified patients on median IFABP and compared biomarkers between "low" and "high" IFABP. Second, by causal mediation analysis, we assessed effects of IFABP through the two most important inflammatory biomarkers, interleukin (IL)-6 and terminal complement complex (TCC), on day two circulatory variables, Sequential Organ Failure Assessment (SOFA)-score, and 30-day mortality.

Results

Cytokines and complement activation were higher in the high IFABP group. In mediation analysis, patients on the 75th percentile of IFABP, compared to the 25th percentile, had 53% (95% CI, 33-74; p < 0.001) higher risk of dying, where 13 (95% CI, 3-23; p = 0.01) percentage points were mediated through an indirect effect of IL-6. Similarly, the indirect effect of IFABP through IL-6 on SOFA-score was significant, but smaller than potential other effects. Effects through IL-6 on circulatory variables, and all effects through TCC, were not statistically significant and/or small.

Conclusion

Effects of intestinal injury mediated through inflammation on organ dysfunction and mortality were limited. Small, but significant, effects through IL-6 were noted.Trial registration: ClinicalTrials.gov: NCT02648061.

Acute liver failure after out-of-hospital cardiac arrest: An observational study

RATIONALE

Apart from hypoxic hepatitis (HH), the hepatic consequences of out-of-hospital cardiac arrest (OHCA) have been little studied. This cohort study aimed to investigate the characteristics of liver dysfunction resulting from OHCA and its association with outcomes.

METHODS

Among the conventional static liver function tests used to define acute liver failure (ALF), we determined which one correlated more closely with the reference indocyanine green (ICG) clearance test in a series of OHCA patients from the CYRUS trial (NCT01595958). Subsequently, we assessed whether ALF, in addition to HH (i.e., acute liver injury), was an independent risk factor for death in a large cohort of OHCA patients admitted to two intensive care units between 2007 and 2017.

RESULTS

ICG clearance, available for 22 patients, was impaired in 17 (77.3%) cases. Prothrombin time (PT) ratio was the only static liver function test that correlated significantly (r = -0.66, p < 0.01) with ICG clearance and was therefore used to define ALF, with the usual cutoff of < 50%. Of the 418 patients included in the analysis (sex ratio: 1.4; median age: 64 [53-75] years; non-shockable rhythm: 73%), 67 (16.0%) presented with ALF, and 61 (14.6%) had HH at admission. On day 28, 337 (80.6%) patients died. Following multivariate analysis, ALF at admission, OHCA occurring at home, absence of bystander, non-cardiac cause of OHCA, low-flow duration ≥ 20 min, and SOFA score excluding liver subscore at admission were independently associated with day 28 mortality.

CONCLUSIONS

ALF occurred frequently after OHCA and, unlike HH, was independently associated with day 28 mortality.

Multiorgan failure in patients after out of hospital resuscitation: a retrospective single center study

BACKGROUND

Information on extracerebral system dysfunction is important for assessing the needs of critically ill patients after cardiac arrest.

AIMS

To describe the prevalence of organ dysfunction and patient severity after out of hospital cardiac arrest (OHCA) using scores commonly used in intensive care and the association between these and mortality.

METHODS

Retrospective analysis of observational data collected in real time in a tertiary medical center where care withdrawal is mostly illegal. Adult patients after nontraumatic OHCA with ROSC who survived for more than two hours were included. Primary outcome-prevalence of organ failure, based on common definitions for organ dysfunction, in the 1 days of hospitalization. Secondary outcomes-rates of survival to hospital discharge and survival with a good neurological outcome (CPC 1 or 2), and associations between organ dysfunction SOFA and APACHE-II scores and outcomes. Associations were assessed using fisher's exact test for categorical variables and Mann-Whitney and T test for continuous variables. Multivariable models were also constructed for all measurements showing associations in previous tests. For severity scores compatibility, we used receiver-operating curve (ROC).

RESULTS

Overall 369 patients (median age 75 years, 65% male) were included. Most arrests (64%) were witnessed, bystander CPR was provided in 15%. Median call to arrival time was 4 min. The presenting rhythm was asystole in 48% and VT/VF in 22%. Cardiovascular causes of arrest predominated (48%, n = 178). The median length of hospitalization was 5 days. Overall 28% of the patients (n = 98) survived to hospital discharge, mostly with a good neurological status (18.7%, n = 57). The rates of organ dysfunction were: hemodynamic instability 65% (n = 247), respiratory dysfunction 94% (n = 296), kidney dysfunction 70% (n = 259), hepatic dysfunction 14% (n = 50). The median SOFA score on day 1 was 9 and the median APACHE II score was 34. Modeling was limited by missing data. Neurological dysfunction (i.e. GCS and seizures) and kidney injury were consistently correlated with the outcomes in the multivariable models. Severity of critical illness assessed by above scoring systems correlated with mortality (all ROC curves had an AUC ranging between 0.728 and 0.849).

CONCLUSIONS

Multiorgan failure is common after ROSC (1-4). Therefore, the management of patients after ROSC may require advanced multidisciplinary care. Scores describing the severity of critical illness should be routinely reported in resuscitation research. Our unique setting where withdrawal of care is illegal, allows assessment of extremely ill patients and may assist in defining margins for futility.

Inflammatory response after out-of-hospital cardiac arrest-Impact on outcome and organ failure development

BACKGROUND

Post-cardiac arrest syndrome that occurs in out-of-hospital cardiac arrest (OHCA) patients is characterized by inflammatory response. We conducted a scoping review of current evidence regarding several inflammatory markers' usefulness for assessment of patient outcome and illness severity. We also discuss the proposed underlying mechanisms leading to inflammatory response after OHCA.

METHODS

We searched the MEDLINE, PubMed Central, Cochrane CENTRAL and Web of Science Core Collection databases with the following search terms: ("inflammation" OR "cytokines") AND "out-of-hospital cardiac arrest." Each inflammatory marker found was combined with "out-of-hospital cardiac arrest" using "AND" to find further relevant studies. We included original studies measuring inflammatory markers in adult OHCA patients that assessed their prognostic capabilities for mortality, neurological outcome, or organ failure severity.

RESULTS

Fifty-nine studies met the inclusion criteria, covering in total 65 different markers. Interleukin-6 (IL-6), procalcitonin (PCT) and C-reactive protein (CRP) were the most studied markers, and they were associated with poor outcomes in 13/15, 13/14 and 11/17 studies, respectively. Based on area under the receiver operating characteristic curve (AUC) value, the time point of best discriminatory capacity for poor outcome was ICU admission for IL-6 (median AUC 0.78, range 0.71-0.98) and day one after OHCA for PCT (median AUC 0.84, range 0.61-0.98). Seven studies reported AUCs for CRP (range 0.52-0.76) with no measurement time point being superior to others. The association of IL-6 and PCT with outcome appeared stronger in studies with more severely ill patients. Studies reported conflicting results regarding each marker's association with organ failure severity.

CONCLUSION

Inflammatory markers are potentially useful for early risk stratification after OHCA. PCT and IL-6 have moderate prognostic value during the first 24 h of the ICU stay. Predictive accuracy appears to be associated with the study overall event rate.

Acute ischemic stroke in a university hospital intensive care unit: 1-year costs and outcome

Background and purpose

Little is currently known about the cost‐effectiveness of intensive care of acute ischemic stroke (AIS). We evaluated 1‐year costs and outcome for patients with AIS treated in the intensive care unit (ICU).

Materials and methods

A single‐center retrospective study of patients admitted to an academic ICU with AIS between 2003 and 2013. True healthcare expenditure was obtained up to 1 year after admission and adjusted to consumer price index of 2019. Patient outcome was 12‐month functional outcome and mortality. We used multivariate logistic regression analysis to identify independent predictors of favorable outcomes and linear regression analysis to assess factors associated with costs. We calculated the effective cost per survivor (ECPS) and effective cost per favorable outcome (ECPFO).

Results

The study population comprised 154 patients. Reasons for ICU admission were: decreased consciousness level (47%) and need for respiratory support (40%). There were 68 (44%) 1 year survivors, of which 27 (18%) had a favorable outcome. High age (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91–0.98) and high hospital admission National Institutes of Health Stroke Scale score (OR 0.92, 95% CI 0.87–0.97) were independent predictors of poor outcomes. Increased age had a cost ratio of 0.98 (95% CI 0.97–0.99) per added year. The ECPS and ECPFO were 115,628€ and 291,210€, respectively.

Conclusions

Treatment of AIS in the ICU is resource‐intense, and in an era predating mechanical thrombectomy the outcome is often poor, suggesting a need for further research into cost‐efficacy of ICU care for AIS patients.

Association of Sequential Organ Failure Assessment (SOFA) components with mortality

BACKGROUND

Sequential Organ Failure Assessment (SOFA) is a practical method to describe and quantify the presence and severity of organ system dysfunctions and failures. Some proposals suggest that SOFA could be employed as an endpoint in trials. To justify this, all SOFA component scores should reflect organ dysfunctions of comparable severity. We aimed to investigate whether the associations of different SOFA components with in-hospital mortality are comparable.

METHODS

We performed a study based on nationwide register data on adult patients admitted to 26 Finnish intensive care units (ICUs) during 2012-2015. We determined the SOFA score as the maximum score in the first 24 hours after ICU admission. We defined organ failure (OF) as an organ-specific SOFA score of three or higher. We evaluated the association of different SOFA component scores with mortality.

RESULTS

Our study population comprised 63,756 ICU patients. Overall hospital mortality was 10.7%. In-hospital mortality was 22.5% for patients with respiratory failure, 34.8% for those with coagulation failure, 40.1% for those with hepatic failure, 14.9% for those with cardiovascular failure, 26.9% for those with neurologic failure and 34.6% for the patients with renal failure. Among patients with comparable total SOFA scores, the risk of death was lower in patients with cardiovascular OF compared with patients with other OFs.

CONCLUSIONS

All SOFA components are associated with mortality, but their weights are not comparable. High scores of other organ systems mean a higher risk of death than high cardiovascular scores. The scoring of cardiovascular dysfunction needs to be updated.

Accumulated Epinephrine Dose is Associated With Acute Kidney Injury Following Resuscitation in Adult Cardiac Arrest Patients

The goal of this study was to investigate the association between total epinephrine dosage during resuscitation and acute kidney injury after return of spontaneous circulation in patients with cardiac arrest. We performed a secondary analysis of previously published data on the resuscitation of cardiac arrest patients. Bivariate, multivariate logistic regression, and subgroup analyses were conducted to investigate the association between total epinephrine dosage during resuscitation and acute kidney injury after return of spontaneous circulation. A total of 312 eligible patients were included. The mean age of the patients was 60.8 ± 15.2 years. More than half of the patients were male (73.4%) and had an out-of-hospital cardiac arrest (61.9%). During resuscitation, 125, 81, and 106 patients received ≤2, 3 - 4, and ≥5 mg epinephrine, respectively. After return of spontaneous circulation, there were 165 patients (52.9%) and 147 patients (47.1%) with and without acute kidney injury, respectively. Both bivariate and multivariate analysis showed a statistically significant association between total epinephrine dosage and acute kidney injury. The subgroup analysis showed that the strength of the association between epinephrine dosage and acute kidney injury varied by location of cardiac arrest. Further multivariate regression analysis found that the association between epinephrine dosage and acute kidney injury was only observed in patients with in-hospital cardiac arrest after adjusting for multiple confounding factors. Compared with in-hospital cardiac arrest patients who received ≤2 mg of epinephrine, patients with 3–4 mg of epinephrine or ≥5 mg of epinephrine had adjusted odds ratios of 4.2 (95% confidence interval 1.0–18.4) and 11.3 (95% confidence interval 2.0–63.0), respectively, to develop acute kidney injury. Therefore, we concluded that a higher epinephrine dosage during resuscitation was associated with an increased incidence of acute kidney injury after return of spontaneous circulation in adult patients with in-hospital cardiac arrest.

Serum fibroblast growth factor 21 levels after out of hospital cardiac arrest are associated with neurological outcome

Fibroblast growth factor (FGF) 21 is a marker associated with mitochondrial and cellular stress. Cardiac arrest causes mitochondrial stress, and we tested if FGF 21 would reflect the severity of hypoxia-reperfusion injury after cardiac arrest. We measured serum concentrations of FGF 21 in 112 patients on ICU admission and 24, 48 and 72 h after out-of-hospital cardiac arrest with shockable initial rhythm included in the COMACARE study (NCT02698917). All patients received targeted temperature management for 24 h. We defined 6-month cerebral performance category 1–2 as good and 3–5 as poor neurological outcome. We used samples from 40 non-critically ill emergency room patients as controls. We assessed group differences with the Mann Whitney U test and temporal differences with linear modeling with restricted maximum likelihood estimation. We used multivariate logistic regression to assess the independent predictive value of FGF 21 concentration for neurologic outcome. The median (inter-quartile range, IQR) FGF 21 concentration was 0.25 (0.094–0.91) ng/ml in controls, 0.79 (0.37–1.6) ng/ml in patients at ICU admission (P < 0.001 compared to controls) and peaked at 48 h [1.2 (0.46–2.5) ng/ml]. We found no association between arterial blood oxygen partial pressure and FGF 21 concentrations. We observed with linear modeling an effect of sample timepoint (F 5.6, P < 0.01), poor neurological outcome (F 6.1, P = 0.01), and their interaction (F 3.0, P = 0.03), on FGF 21 concentration. In multivariate logistic regression analysis, adjusting for relevant clinical covariates, higher average FGF 21 concentration during the first 72 h was independently associated with poor neurological outcome (odds ratio 1.60, 95% confidence interval 1.10–2.32). We conclude that post cardiac arrest patients experience cellular and mitochondrial stress, reflected as a systemic FGF 21 response. This response is higher with a more severe hypoxic injury but it is not exacerbated by hyperoxia.

The 'Weekend Effect' in adult patients who receive extracorporeal cardiopulmonary resuscitation after in- and out-of-hospital cardiac arrest

Aim

This study investigates the potentially adverse association between extracorporeal cardiopulmonary resuscitation (ECPR) after cardiac arrest on weekends versus weekdays.

Methods

Single-centre, retrospective, stratified (weekday versus weekend) analysis of 318 patients who underwent in-hospital ECPR after out-of-hospital and in-hospital cardiac arrest (OHCA/IHCA) between 01/2008 and 12/2018. Weekend was defined as the period between Friday 17:00 and Monday 06:59.

Results

Seventy-three patients (23%) received ECPR during the weekend and 245 arrests (77%) occurred during the weekday. Whereas survival to discharge did not differ between both groups, long-term survival was significantly lower in the weekend group (p = 0.002). In the multivariate analysis, independent risk factors associated with hospital mortality were no flow time (OR 1.014; 95% CI 1.004–1.023) and serum lactate prior ECPR (OR 1.011; 95% CI 1.006–1.012), whereas each unit serum haemoglobin above average had a protective effect on in-hospital mortality (OR 0.87; 95% CI 0.79–0.96). New onset kidney failure requiring renal replacement therapy occurred more often in the weekend group (30.1% versus 18.4%; p = 0.04). One third of patients experienced complications regardless ECPR was initiated at weekdays or weekends.

Conclusion

Extracorporeal cardiopulmonary resuscitation at weekends adversely seems to impact long-term survival regardless timing (dayshift/nightshift). Duration of CPR and serum lactate prior ECPR were demonstrated as independent risk factors for in-hospital mortality. As ECPR at weekends could not be shown to be an independent outcome predictor a thorough analysis of clinical events subsequent to this intervention is warranted to understand long-term consequences of ECPR initiation after cardiac arrest.

Use of SOFA score in cardiac arrest research: A scoping review

Background

The Sequential Organ Failure Assessment (SOFA) score is a commonly used severity-of-illness score in cardiac arrest research. Due to its nature, the SOFA score often has missing data. How much data is missing and how that missing data is handled is unknown.

Objectives

We conducted a scoping review on cardiac arrest studies using SOFA, focusing on missing data.

Data sources

PubMed, Embase, and Web of Science.

Study selection

All English-language peer-reviewed studies of cardiac arrest with SOFA as an outcome or exposure were included.

Data extraction

For each study, quantity of missing SOFA data, analytic strategy to handle missing SOFA variables, whether/to what degree mortality influenced the amount of missing SOFA scores), SOFA score modifications, and number of SOFA measurements was extracted.

Data synthesis

We included 66 studies published between 2006–2019. Five studies were randomized controlled trials, 26 were prospective cohort studies, and 25 were retrospective cohort studies. SOFA was used as an outcome in 36 (55%) and a primary outcome in 10 (15%). Nine studies (14%) mentioned the quantity of missing SOFA data, which ranged from 0 to 76% (median: 10% [IQR: 6%, 42%]). Twenty-seven (41%) studies reported a method to handle missing SOFA. The most common method used excluded subjects with missing data (81%). In the 50 studies using serial SOFA scores, 11 (22%) documented mortality prior to SOFA measurement; which ranged from 3% to 76% (median: 12% [IQR: 6%–35%]).

Conclusions

Missing data is common in cardiac arrest research using SOFA scores. Variability exists in reporting and handling missing SOFA variables.

The Sequential Organ Failure Assessment (SOFA) score predicts mortality and neurological outcome in patients with post-cardiac arrest syndrome

BACKGROUND

Patients experiencing out-of-hospital cardiac arrest (OHCA) and subsequent post-cardiac arrest syndrome are often compromised by multi-organ failure. The Sequential Organ Failure Assessment (SOFA) score has been used to predict clinical outcome of patients requiring intensive care for multi-organ failure. Thus, the assessment of SOFA score is recommended as a criterion for sepsis. Although post-cardiac arrest patients frequently develop sepsis-like status in ICU, there are limited reports evaluating the SOFA score in post-cardiac arrest patients. We investigated the predictive value of the SOFA score in survival and neurological outcomes in patients with post-cardiac arrest syndrome.

METHODS

A total of 231 cardiovascular arrest patients achieving return of spontaneous circulation (ROSC) were finally extracted from the institutional consecutive database comprised of 1218 OHCA patients transferred to the institution between January 2015 and July 2018. The SOFA score was calculated on admission and after 48h. Predictors of survival and neurological outcome defined as having cerebral-performance-category (CPC) 1 or 2 at 30 days were determined.

RESULTS

SOFA score was lower in survived patients (5.0 vs 10.0, p<0.001) and those with favorable neurological outcome (5.0 vs 8.0, p<0.001) as compared with the counterparts. The SOFA score on admission was an independent predictor of survival (OR 0.68, 95% confidence interval [CI] 0.59-0.78; p<0.001) and favorable neurological performance (OR 0.79; 95% CI 0.69-0.90; p<0.001) at 30 days. Furthermore, a change in SOFA score (48-0h) was predictive of favorable 30-day neurological outcome (OR 0.71, 95% CI 0.60-0.85; p<0.001).

CONCLUSIONS

Evaluation of the SOFA score in the ICU is useful to predict survival and neurological outcome in post-cardiac arrest patients.

Red blood cell distribution width predicts long-term mortality in critically ill patients with acute kidney injury: a retrospective database study

Acute kidney injury (AKI) is a serious complication in the intensive care unit (ICU), which may increase the mortality of critically ill patients. The red blood cell distribution width (RDW) has proved useful as a predictor of short-term prognosis in critically ill patients with AKI. However, it remains unknown whether RDW has a prognostic value of long-term all-cause mortality in these patients. The data of 18279 critically ill patients with AKI at first-time hospital admission were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The tertiles of the RDW values were used to divide subjects into three groups, namely RDW < 13.6% for the low RDW group, 13.6% ≤ RDW < 15.2% for the middle RDW group and RDW ≥ 15.2% for the high RDW group. Demographic data, mortality, 4-year survival time and severity scale scores were compared among groups. The Kaplan-Meier analysis and the Cox regression analysis were performed to assess the impact of RDW on all-cause mortality in AKI patients. The receiver operating characteristic (ROC) curve analysis was done to evaluate the prognostic value of RDW on the long-term outcome of critically ill patients with AKI. The median age of the enrolled subjects was 65.6 years. AKI patients with a higher RDW value had significantly shorter survival time and higher death rate. By the Kaplan-Meier analysis, patients in the higher RDW group presented significantly shorter survival time and higher death rate. The Cox regression model indicated RDW as an independent risk factor of all-cause mortality of AKI patients (HR 1.219, 95% CI, 1.211 to 1.228). By the ROC analysis, RDW appeared more efficient in predicting long-term prognosis as compared with conventional severity scales. The AUC of RDW (95% CI, 0.712 to 0.725) was significantly higher than other severity scale scores. In conclusion, RDW is positively correlated to survival time of 4-year follow-up in critically ill patients with AKI, and RDW is an independent prognostic factor of long-term outcomes of these patients.