Elsevier

Resuscitation

Volume 76, Issue 2, February 2008, Pages 214-220
Resuscitation

Clinical paper
Strict normoglycaemic blood glucose levels in the therapeutic management of patients within 12 h after cardiac arrest might not be necessary

https://doi.org/10.1016/j.resuscitation.2007.08.003Get rights and content

Summary

Aim of the study

The admission blood glucose level after cardiac arrest is predictive of outcome. However the blood glucose levels in the post-resuscitation period, that are optimal remains a matter of debate. We wanted to assess an association between blood glucose levels at 12 h after restoration of spontaneous circulation and neurological recovery over 6 months.

Materials and methods

A total of 234 patients from a multi-centre trial examining the effect of mild hypothermia on neurological outcome were included. According to the serum glucose level at 12 h after restoration of spontaneous circulation, quartiles (Q) were generated: Median (range) glucose concentrations were for QI 100 (67–115 mg/dl), QII 130 (116–143 mg/dl), QIII 162 (144–193 mg/dl) and QIV 265 (194–464 mg/dl).

Results

In univariate analysis there was a strong non-linear association between blood glucose and good neurological outcome (odds ratio compared to QIV): QI 8.05 (3.03–21.4), QII 13.41 (4.9–36.67), QIII 1.88 (0.67–5.26). After adjustment for sex, age, “no-flow” and “low-flow” time, adrenaline (epinephrine) dose, history of coronary artery disease and myocardial infarction, and therapeutic hypothermia, this association still remained strong: QI 4.55 (1.28–16.12), QII 13.02 (3.29–49.9), QIII 1.37 (0.38–5.64).

Conclusion

There is a strong non-linear association of survival with good neurological outcome and blood glucose levels 12 h after cardiac arrest even after adjusting for potential confounders. Not only strict normoglycaemia, but also blood glucose levels from 116 to 143 mg/dl were correlated with survival and good neurological outcome, which might have an important therapeutic implication.

Introduction

Sudden cardiac death is a major clinical and public health problem1 and the long-term prognosis of cardiac arrest survivors is still poor.2, 3 Only about one third of all patients admitted to a hospital after cardiac arrest can be discharged.4 Two third of the patients dying after admission die from neurological injury.5

Prediction of survival and neurological outcome remains difficult, especially in the first 48 h after cardiac arrest.6 High blood glucose on admission has been shown to be associated with adverse outcome and mortality in patients with cardiac arrest, myocardial infarction and stroke.7, 8, 9, 10, 11, 12 In cardiac arrest patients, this admission blood glucose has also been considered to be a surrogate for a long interval to restoration of spontaneous circulation.

Since the studies of Van den Berghe,13, 14 blood glucose control has become an important issue in the treatment of critical ill patients. And therefore the new guidelines for cardiopulmonary resuscitation,15 recommend monitoring blood glucose frequently and treat hyperglycaemia in patients after cardiac arrest. But the optimum blood glucose target has not yet been determined.

In this study we aim to validate the relationship between blood glucose values 12 h after restoration of spontaneous circulation and survival with good neurological recovery to see, if strict normoglycaemia is necessary within this time. In addition the association of blood glucose levels in the application of “mild therapeutic hypothermia” and “no-flow” times (time interval from collapse to cardiopulmonary resuscitation), “low-flow” times (time interval of cardiopulmonary resuscitation) and the dose of adrenaline (epinephrine) used during resuscitation was investigated.

Section snippets

Materials and methods

The data set of the prospective randomised European multicentre trial on mild therapeutic hypothermia to improve neurological outcome after cardiac arrest16 has been analysed retrospectively. The work was approved by the appropriate ethical committees related to the institutions in which it was performed.

Patients aged 18–75 years in whom spontaneous circulation had been restored after witnessed cardiac arrest due to ventricular fibrillation or non-perfusing ventricular tachycardia were assigned

Results

Between March 1996 and January 2001, 275 patients were enrolled into the hypothermia after cardiac arrest trial. In exploratory analyses we found an interaction between a known history of diabetes mellitus and the effect of glucose levels on neurological outcome. Since the small number of diabetic patients did not allow a separate analysis, all patients with a known history of diabetes (n = 37) were excluded. Furthermore, four patients were excluded because information on diabetes was missing.

Discussion

This retrospective analysis of data obtained from a previous randomised clinical trial about the effect of mild hypothermia after cardiac arrest on survival and neurological recovery16 demonstrates that moderate elevation of blood glucose at 12 h after cardiac arrest is associated with good outcome. Survival and good neurological recovery showed to be better independently from all confounders such as “no-flow” and “low-flow” time or epinephrine dose administered during cardiopulmonary

Conclusion

Blood glucose levels 12 h after return of spontaneous circulation are predictive not only for survival but also for neurological outcome, independently from no-flow, low-flow time and epinephrine dosage. Near normoglycaemic blood glucose levels (67–115 mg/dl; 3.72–6.38 mmol/l) were not associated with better neurological outcome than a blood glucose level of 116–143 mg/dl (6.44–7.94 mmol/l), which has an important therapeutic implication. Further prospective studies are necessary to determine the

Conflict of interest

There is no conflict of interest.

Funding source

Supported by grants from BIOMED2 European Commission, DG XII for Science Research and Development, Directorate Life Science and Technologies, Biomedical and Health Research Division (BMH4-CD-96-0667); Ministry of Science and Transport, Austria (GZ 5.550/12-Pr/4/95, GZ 650.0251/2-IV/6/96); and Austrian Science Foundation (P11405-MED).

Acknowledgments

We are indebted to the Hypothermia After Cardiac Arrest (HACA) Study Group investigators [A. Zeiner (Universitätsklinik für Notfallmedizin, Vienna, Austria; 88 patients); A. Valentin (Krankenhaus Rudolfstiftung, Vienna, Austria; 2 patients); M. De Meyer (A.Z. Sint Jan, Bruges, Belgium; 35 patients); O. Takkunen (Helsingin yliopistollinen keskussairaala, Helsinki, Finland; 71 patients); S. Hachimi-Idrissi, L. Huyghens (Academisch Ziekenhuis van de Vrije Universiteit Brussel, Brussels, Belgium;

References (24)

  • W.T. Longstreth et al.

    Neurologic outcome and blood glucose levels during out-of-hospital cardiopulmonary resuscitation

    Neurology

    (1986)
  • W.T. Longstreth et al.

    High blood glucose level on hospital admission and poor neurological recovery after cardiac arrest

    Ann Neurol

    (1984)
  • Cited by (94)

    • Neurologic complications of cardiac arrest

      2021, Handbook of Clinical Neurology
    • Cardiopulmonary Resuscitation

      2016, Smith's Anesthesia for Infants and Children, Ninth Edition
    • Metabolic and electrolyte disturbance after cardiac arrest: How to deal with it

      2015, Best Practice and Research: Clinical Anaesthesiology
    View all citing articles on Scopus

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2007.08.003.

    View full text