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Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort

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Abstract

Objective

Brain injury is well established as a cause of early mortality after out-of-hospital cardiac arrest (OHCA), but postresuscitation shock also contributes to these deaths. This study aims to describe the respective incidence, risk factors, and relation to mortality of post-cardiac arrest (CA) shock and brain injury.

Design

Retrospective analysis of an observational cohort.

Setting

24-bed medical intensive care unit (ICU) in a French university hospital.

Patients

All consecutive patients admitted following OHCA were considered for analysis. Post-CA shock was defined as a need for infusion of vasoactive drugs after resuscitation. Death related to brain injury included brain death and care withdrawal for poor neurological evolution.

Intervention

None.

Measurements and main results

Between 2000 and 2009, 1,152 patients were admitted after OHCA. Post-CA shock occurred in 789 (68 %) patients. Independent factors associated with its onset were high blood lactate and creatinine levels at ICU admission. During the ICU stay, 269 (34.8 %) patients died from post-CA shock and 499 (65.2 %) from neurological injury. Age, raised blood lactate and creatinine values, and time from collapse to restoration of spontaneous circulation increased the risk of ICU mortality from both shock and brain injury, whereas a shockable rhythm was associated with reduced risk of death from these causes. Finally, bystander cardiopulmonary resuscitation (CPR) decreased the risk of death from neurological injury.

Conclusions

Brain injury accounts for the majority of deaths, but post-CA shock affects more than two-thirds of OHCA patients. Mortality from post-CA shock and brain injury share similar risk factors, which are related to the quality of the rescue process.

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References

  1. Sasson C, Rogers MA, Dahl J, Kellermann AL (2010) Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 3:63–81

    Article  PubMed  Google Scholar 

  2. Zandbergen EG, de Haan RJ, Reitsma JB, Hijdra A (2003) Survival and recovery of consciousness in anoxic-ischemic coma after cardiopulmonary resuscitation. Intensive Care Med 29:1911–1915

    Article  PubMed  Google Scholar 

  3. Laver S, Farrow C, Turner D, Nolan J (2004) Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 30:2126–2128

    Article  PubMed  Google Scholar 

  4. Adrie C, Cariou A, Mourvillier B, Laurent I, Dabbane H, Hantala F, Rhaoui A, Thuong M, Monchi M (2006) Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score. Eur Heart J 27:2840–2845

    Article  PubMed  Google Scholar 

  5. Booth CM, Boone RH, Tomlinson G, Detsky AS (2004) Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA 291:870–879

    Article  PubMed  CAS  Google Scholar 

  6. Bouwes A, Binnekade JM, Kuiper MA, Bosch FH, Zandstra DF, Toornvliet AC, Biemond HS, Kors BM, Koelman JH, Verbeek MM, Weinstein HC, Hijdra A, Horn J (2012) Prognosis of coma after therapeutic hypothermia: a prospective cohort study. Ann Neurol 71:206–212

    Article  PubMed  Google Scholar 

  7. Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K (2007) Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC case mix programme database. Anaesthesia 62:1207–1216

    Article  PubMed  CAS  Google Scholar 

  8. Mongardon N, Dumas F, Ricome S, Grimaldi D, Hissem T, Pène F, Cariou A (2011) Postcardiac arrest syndrome: from immediate resuscitation to long-term outcome. Ann Intensive Care 1:45

    Article  PubMed  Google Scholar 

  9. Grace PA (1994) Ischaemia-reperfusion injury. Br J Surg 81:637–647

    Article  PubMed  CAS  Google Scholar 

  10. Negovsky VA (1972) The second step in resuscitation–the treatment of the ‘post-resuscitation disease’. Resuscitation 1:1–7

    Article  PubMed  CAS  Google Scholar 

  11. Chang WT, Ma MH, Chien KL, Huang CH, Tsai MS, Shih FY, Yuan A, Tsai KC, Lin FY, Lee YT, Chen WJ (2007) Postresuscitation myocardial dysfunction: correlated factors and prognostic implications. Intensive Care Med 33:88–95

    Article  PubMed  Google Scholar 

  12. Laurent I, Monchi M, Chiche JD, Joly LM, Spaulding C, Bourgeois B, Cariou A, Rozenberg A, Carli P, Weber S, Dhainaut JF (2002) Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 40:2110–2116

    Article  PubMed  Google Scholar 

  13. Huet O, Dupic L, Batteux F, Matar C, Conti M, Chereau C, Lemiale V, Harrois A, Mira JP, Vicaut E, Cariou A, Duranteau J (2011) Postresuscitation syndrome: potential role of hydroxyl radical-induced endothelial cell damage. Crit Care Med 39:1712–1720

    Article  PubMed  CAS  Google Scholar 

  14. Adrie C, Laurent I, Monchi M, Cariou A, Dhainaut JF, Spaulding C (2004) Postresuscitation disease after cardiac arrest: a sepsis-like syndrome? Curr Opin Crit Care 10:208–212

    Article  PubMed  Google Scholar 

  15. Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T (2013) The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 84:337–342

    Article  PubMed  Google Scholar 

  16. Hypothermia after cardiac arrest study group (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346:549–556

    Article  Google Scholar 

  17. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K (2002) Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346:557–563

    Article  PubMed  Google Scholar 

  18. Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, Bossaert L, Delooz HH, Dick WF, Eisenberg MS (1991) Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 84:960–975

    Article  PubMed  CAS  Google Scholar 

  19. Dumas F, Grimaldi D, Zuber B, Fichet J, Charpentier J, Pène F, Vivien B, Varenne O, Carli P, Jouven X, Empana JP, Cariou A (2011) Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients?: insights from a large registry. Circulation 123:877–886

    Article  PubMed  Google Scholar 

  20. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, Empana JP, Carli P, Mira JP, Jouven X, Spaulding C (2010) Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv 3:200–207

    Article  PubMed  Google Scholar 

  21. Perbet S, Mongardon N, Dumas F, Bruel C, Lemiale V, Mourvillier B, Carli P, Varenne O, Mira JP, Wolff M, Cariou A (2011) Early-onset pneumonia after cardiac arrest: characteristics, risk factors and influence on prognosis. Am J Respir Crit Care Med 184:1048–1054

    Article  PubMed  Google Scholar 

  22. Carli P (2008) Prise en charge de l’arrêt cardiaque. Réanimation 17:297–307

    Article  Google Scholar 

  23. Walters EL, Morawski K, Dorotta I (2011) Implementation of a post-cardiac arrest care bundle including therapeutic hypothermia and hemodynamic optimization in patients with return of spontaneous circulation after out-of-hospital cardiac arrest: A feasibility study. Shock 35:360–366

    Article  PubMed  Google Scholar 

  24. Adrie C, Adib-Conquy M, Laurent I, Monchi M, Vinsonneau C, Fitting C, Fraisse F, Dinh-Xuan AT, Carli P, Spaulding C, Dhainaut JF, Cavaillon JM (2002) Successful cardiopulmonary resuscitation after cardiac arrest as a “sepsis-like” syndrome. Circulation 106:562–568

    Article  PubMed  Google Scholar 

  25. Laurent I, Adrie C, Vinsonneau C, Cariou A, Chiche JD, Ohanessian A, Spaulding C, Carli P, Dhainaut JF, Monchi M (2005) High-volume hemofiltration after out-of-hospital cardiac arrest: a randomized study. J Am Coll Cardiol 46:432–437

    Article  PubMed  Google Scholar 

  26. Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, Katsios N, Papastylianou A, Gkisioti S, Stathopoulos A, Kollintza A, Stamataki E, Roussos C (2009) Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med 169:15–24

    Article  PubMed  CAS  Google Scholar 

  27. Le Guen M, Nicolas-Robin A, Carreira S, Raux M, Leprince P, Riou B, Langeron O (2011) Extracorporeal life support following out-of-hospital refractory cardiac arrest. Crit Care 15:R29

    Article  PubMed  Google Scholar 

  28. Skulec R, Kovarnik T, Dostalova G, Kolar J, Linhart A (2008) Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome. Acta Anaesthesiol Scand 52:188–194

    Article  PubMed  CAS  Google Scholar 

  29. Hovdenes J, Laake JH, Aaberge L, Haugaa H, Bugge JF (2007) Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock. Acta Anaesthesiol Scand 51:137–142

    Article  PubMed  CAS  Google Scholar 

  30. Zobel C, Adler C, Kranz A, Seck C, Pfister R, Hellmich M, Kochanek M, Reuter H (2012) Mild therapeutic hypothermia in cardiogenic shock syndrome. Crit Care Med 40:1715–1723

    Article  PubMed  Google Scholar 

  31. Oddo M, Schaller MD, Feihl F, Ribordy V, Liaudet L (2006) From evidence to clinical practice: effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest. Crit Care Med 34:1865–1873

    PubMed  Google Scholar 

  32. Oddo M, Ribordy V, Feihl F, Rossetti AO, Schaller MD, Chioléro R, Liaudet L (2008) Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular fibrillation cardiac arrest treated with hypothermia: a prospective study. Crit Care Med 36:2296–2301

    Article  PubMed  Google Scholar 

  33. Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, Draegni T, Steen PA (2007) Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73:29–39

    Article  PubMed  Google Scholar 

  34. Arrich J (2007) European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group. Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med 35:1041–1047

    Article  PubMed  Google Scholar 

  35. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, Valsson F, Wanscher M, Friberg H (2009) Hypothermia Network. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 53:926–934

    Article  PubMed  CAS  Google Scholar 

  36. Gupta A, Allaqaband S, Bajwa T (2009) Combined use of Impella device and intra-aortic balloon pump to improve survival in a patient in profound cardiogenic shock post cardiac arrest. Catheter Cardiovasc Interv 74:975–976

    Article  PubMed  Google Scholar 

  37. Mégarbane B, Leprince P, Deye N, Résière D, Guerrier G, Rettab S, Théodore J, Karyo S, Gandjbakhch I, Baud FJ (2007) Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest. Intensive Care Med 33:758–764

    Article  PubMed  Google Scholar 

  38. Böttiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, Carli PA, Adgey JA, Bode C, Wenzel V (2008) TROICA Trial Investigators; European Resuscitation Council Study Group. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 359:2651–2662

    Article  PubMed  Google Scholar 

  39. Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L (2009) Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA 302:2222–2229

    Article  PubMed  Google Scholar 

  40. Adrie C, Haouache H, Saleh M, Memain N, Laurent I, Thuong M, Darques L, Guerrini P, Monchi M (2008) An underrecognized source of organ donors: patients with brain death after successfully resuscitated cardiac arrest. Intensive Care Med 34:132–137

    Article  PubMed  CAS  Google Scholar 

  41. Fischer C, Luauté J, Némoz C, Morlet D, Kirkorian G, Mauguière F (2006) Editorial response: evoked potentials can be used as a prognosis factor for awakening. Crit Care Med 34:2025

    Article  PubMed  Google Scholar 

  42. Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Böttiger B, ERC Guidelines Writing Group (2010) European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 81:1219–1276

    Article  PubMed  Google Scholar 

  43. De Groot YJ, Lingsma HF, Bakker J, Gommers DA, Steyerberg E, Kompanje EJ (2012) External validation of a prognostic model predicting time of death after withdrawal of life support in neurocritical patients. Crit Care Med 40:233–238

    Article  PubMed  Google Scholar 

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Correspondence to Virginie Lemiale.

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Lemiale, V., Dumas, F., Mongardon, N. et al. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med 39, 1972–1980 (2013). https://doi.org/10.1007/s00134-013-3043-4

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  • DOI: https://doi.org/10.1007/s00134-013-3043-4

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