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Rasmussen SB, Jeppesen KK, Kjaergaard J, Hassager C, Schmidt H, Mølstrøm S, Beske RP, Grand J, Ravn HB, Winther-Jensen M, Meyer MAS, Møller JE. Blood Pressure and Oxygen Targets on Kidney Injury After Cardiac Arrest. Circulation 2023; 148:1860-1869. [PMID: 37791480 DOI: 10.1161/circulationaha.123.066012] [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] [Received: 06/18/2023] [Accepted: 09/06/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) represents a common and serious complication to out-of-hospital cardiac arrest. The importance of post-resuscitation care targets for blood pressure and oxygenation for the development of AKI is unknown. METHODS This is a substudy of a randomized 2-by-2 factorial trial, in which 789 comatose adult patients who had out-of-hospital cardiac arrest with presumed cardiac cause and sustained return of spontaneous circulation were randomly assigned to a target mean arterial blood pressure of either 63 or 77 mm Hg. Patients were simultaneously randomly assigned to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa or a liberal oxygenation target of a Pao2 of 13 to 14 kPa. The primary outcome for this study was AKI according to KDIGO (Kidney Disease: Improving Global Outcomes) classification in patients surviving at least 48 hours (N=759). Adjusted logistic regression was performed for patients allocated to high blood pressure and liberal oxygen target as reference. RESULTS The main population characteristics at admission were: age, 64 (54-73) years; 80% male; 90% shockable rhythm; and time to return of spontaneous circulation, 18 (12-26) minutes. Patients allocated to a low blood pressure and liberal oxygen target had an increased risk of developing AKI compared with patients with high blood pressure and liberal oxygen target (84/193 [44%] versus 56/187 [30%]; adjusted odds ratio, 1.87 [95% CI, 1.21-2.89]). Multinomial logistic regression revealed that the increased risk of AKI was only related to mild-stage AKI (KDIGO stage 1). There was no difference in risk of AKI in the other groups. Plasma creatinine remained high during hospitalization in the low blood pressure and liberal oxygen target group but did not differ between groups at 6- and 12-month follow-up. CONCLUSIONS In comatose patients who had been resuscitated after out-of-hospital cardiac arrest, patients allocated to a combination of a low mean arterial blood pressure and a liberal oxygen target had a significantly increased risk of mild-stage AKI. No difference was found in terms of more severe AKI stages or other kidney-related adverse outcomes, and creatinine had normalized at 1 year after discharge. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03141099.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | | | - Jesper Kjaergaard
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.K., C.H.)
| | - Christian Hassager
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.K., C.H.)
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | - Rasmus Paulin Beske
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Johannes Grand
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Hanne Berg Ravn
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
| | - Matilde Winther-Jensen
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Martin Abild Stengaard Meyer
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology (K.K.J., J.E.M.), Odense University Hospital, Denmark
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
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The Influence of Ultra-Low Tidal Volume Ventilation during Cardiopulmonary Resuscitation on Renal and Hepatic End-Organ Damage in a Porcine Model. Biomedicines 2023; 11:biomedicines11030899. [PMID: 36979878 PMCID: PMC10045409 DOI: 10.3390/biomedicines11030899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
The optimal ventilation strategy during cardiopulmonary resuscitation (CPR) has eluded scientists for years. This porcine study aims to validate the hypothesis that ultra-low tidal volume ventilation (tidal volume 2–3 mL kg−1; ULTVV) minimizes renal and hepatic end-organ damage when compared to standard intermittent positive pressure ventilation (tidal volume 8–10 mL kg−1; IPPV) during CPR. After induced ventricular fibrillation, the animals were ventilated using an established CPR protocol. Upon return of spontaneous circulation (ROSC), the follow-up was 20 h. After sacrifice, kidney and liver samples were harvested and analyzed histopathologically using an Endothelial, Glomerular, Tubular, and Interstitial (EGTI) scoring system for the kidney and a newly developed scoring system for the liver. Of 69 animals, 5 in the IPPV group and 6 in the ULTVV group achieved sustained ROSC and were enlisted, while 4 served as the sham group. Creatinine clearance was significantly lower in the IPPV-group than in the sham group (p < 0.001). The total EGTI score was significantly higher for ULTVV than for the sham group (p = 0.038). Aminotransferase levels and liver score showed no significant difference between the intervention groups. ULTVV may be advantageous when compared to standard ventilation during CPR in the short-term ROSC follow-up period.
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