Vasopressor requirement during targeted temperature management for out-of-hospital cardiac arrest caused by acute myocardial infarction without cardiogenic shock

Survival, but not the severity of hypoxic-ischemic encephalopathy, is associated with higher mean arterial blood pressure after cardiac arrest: a retrospective cohort study

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.

Saline versus Plasma Solution-A in Initial Resuscitation of Patients with Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

BACKGROUND

Although saline is commonly used during cardiopulmonary resuscitation (CPR) or post-cardiac arrest care, it has detrimental effects. This trial aimed to evaluate the efficacy of a balanced crystalloid solution (Plasma Solution-A [PS]) in out-of-hospital cardiac arrest (OHCA) patients and compare it with the efficacy of saline.

METHODS

A randomized, unblinded clinical trial was conducted using PS and saline for intravenous fluid administration during CPR and post-cardiac arrest care of non-traumatic OHCA patients admitted to the emergency department of a tertiary university hospital. Patients received saline (saline group) or PS (PS group) within 24 h of hospital arrival. The primary outcomes were changes in arterial pH, bicarbonate, base excess (BE), and chloride levels within 24 h. The secondary outcomes were clinical outcomes including mortality.

RESULTS

Of the 364 patients, data from 27 and 26 patients in the saline and PS groups, respectively, were analyzed. Analysis using a linear mixed model revealed a significant difference in BE change over time between the groups (treatment-by-time p = 0.044). Increase in BE and bicarbonate levels from 30 min to 2 h was significantly greater (p = 0.044 and p = 0.024, respectively) and the incidence of hyperchloremia was lower (p < 0.001) in the PS group than in the saline group. However, there was no difference in clinical outcomes.

CONCLUSION

Use of PS for resuscitation resulted in a faster improvement in BE and bicarbonate, especially in the early phase of post-cardiac arrest care, and lower hyperchloremia incidence than the use of saline, without differences in clinical outcomes, in OHCA patients.

Optimal timing to measure optic nerve sheath diameter as a prognostic predictor in post-cardiac arrest patients treated with targeted temperature management

AIM

We evaluated the optimal timing of optic nerve sheath diameter (ONSD) measurement to predict neurologic outcome in post-cardiac arrest patients treated with target temperature management (TTM).

METHODS

This was a prospective single-centre observational study from April 2018 to March 2019. Good outcome was defined as the Glasgow-Pittsburgh cerebral performance categories (CPC) 1 or 2, and poor outcome as a CPC between 3 and 5. ONSD was measured initially after return of spontaneous circulation (ROSC) (ONSD_initial), at 24 h (ONSD₂₄), 48 h (ONSD₄₈), and 72 h (ONSD₇₂) using ultrasonography. The receiver operating characteristic (ROC) curves and DeLong method were used to compare the values for predicting neurologic outcomes.

RESULTS

Out of the 36 patients enrolled, 18 had a good outcome. ONSD₂₄, ONSD₄₈, and ONSD₇₂ were higher in the poor outcome group. The area under ROC curve of ONSD₂₄ was 0.91 (95% confidence interval 0.77-0.98) in predicting poor neurologic outcomes. With a cut off value of 4.90 mm, ONSD₂₄ had a sensitivity of 83.3% and a specificity of 94.4% in predicting poor neurologic outcomes.

CONCLUSION

Our findings demonstrate ONSD₂₄ as a valuable tool to predict the neurologic outcome in post-cardiac arrest patients treated with TTM. Therefore, we recommend performing ONSD measurement using ultrasonography at 24 h after ROSC, rather than immediately after ROSC, to predict neurologic outcome in post-cardiac arrest patients treated with TTM.

The Relationship Between the Decreased Rate of Initial Blood Glucose and Neurologic Outcomes in Survivors of Out-of-Hospital Cardiac Arrest Receiving Therapeutic Hypothermia

BACKGROUND

Hyperglycemia in out-of-hospital cardiac arrest (OHCA) survivors is associated with poor outcomes. However, in the control of initial hyperglycemia, an adequate strategy to improve patients' neurologic outcomes remains undetermined. Prior to the establishment of such strategy, we need to determine whether a decreased rate of initial blood glucose (BG) affects patient outcomes.

METHODS

One hundred and forty-five adult non-traumatic OHCA survivors treated with therapeutic hypothermia between April 2007 and December 2011 were enrolled in this single-center retrospective cohort study. Based on the cerebral performance category (CPC) at 6 months after OHCA, study populations were categorized as "Good CPC group" (favorable outcome, CPC1 and CPC2) and "Poor CPC group" (unfavorable outcome, CPC3-CPC5). Variables related to BG were obtained, and the rate of BG change was calculated.

RESULTS

In the Good CPC group, the time required to attain target BG levels was shorter [7.4 (2.97-18.13) vs. 13.17 (7.55-27.0) h, p < 0.001], and the average rate of glucose decrease until the attainment of target BG levels was faster [17.06 (6.67-34.49) vs. 8.33 (4.26-18.55) mg/dl/h, p = 0.005] than in the Poor CPC group. Using multivariate analysis, the faster rate (odds ratio 1.074; 95% confidence interval 1.029-1.12; p = 0.001) and the shorter time (odds ratio 13.888; 95% confidence interval 2.271-84.906; p = 0.004) required to attain target BG levels were independently related to favorable neurologic outcomes.

CONCLUSIONS

Faster rates of initial BG decrease and the shorter time required to attain target BG levels were associated with favorable neurologic outcome in survivors of OHCA receiving therapeutic hypothermia.