Clinical paperThe impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients☆
Introduction
Despite improvements in the early management of cardiac arrest (CA) over the last few decades, prognosis remains poor, with a small percentage of patients surviving to hospital admission and a high mortality rate [1]. Moreover, among comatose CA survivors, extensive brain damage remains a major concern and is responsible for almost two thirds of deaths or decisions to limit life-sustaining therapies in this patient population [2]. Although the majority of post-anoxic brain injury occurs at the moment of cessation of brain perfusion, secondary brain damage, including brain hypoperfusion and reperfusion injuries, may develop in these patients and may contribute to further reduce the likelihood of a favourable neurological recovery [3].
As such, haemodynamic monitoring and therapeutic strategies should be considered in these patients to optimise the administration of inotropic and vasopressor agents and to maintain adequate cerebral perfusion pressure and oxygen delivery in the post-resuscitation phase. However, no randomised clinical studies have defined the optimal haemodynamic strategy to achieve these goals. Although current guidelines recommend that mean arterial pressure (MAP) should be titrated to values greater than 65 mmHg in such patients [4], values should probably be individualised [5]. Indeed, the lower threshold of cerebral autoregulation is often shifted rightward in this setting, meaning that in some patients a MAP of 65 mmHg may still result in brain hypoperfusion and in large variation of cerebral blood flow [6]. Moreover, several studies have shown that a higher MAP (>80 mmHg) could be associated with better outcome and adequate cerebral oxygenation [7,8]. Unfortunately, this evidence remains weak due to the observational design of those studies and the limited number and heterogeneity of the patients included.
In the early phase after hospital admission, almost half CA survivors develop shock [9]. In the presence of shock (i.e. need for vasopressor agents and signs of hypoperfusion), using vasopressor agents to achieve higher blood pressure targets may be detrimental despite the improvement in cerebral perfusion pressure, because of an increase in cardiac complications, such as arrhythmias, coronary ischaemia and heart failure, secondary to the increased afterload [10]. In the setting of cardiogenic shock, higher MAP, cardiac power index, and lower simplified acute physiology score II (SAPS II) were independently associated with better survival rates in one study [11], whereas the minimum diastolic arterial pressure (DAP) in the first 6 h was independently associated with 28-day mortality in another study [12].
We, therefore, designed this study to investigate the relationship between early haemodynamic variables and neurological outcome in comatose survivors after CA.
Section snippets
Study population
This retrospective study was performed in the 35-bed medico-surgical Department of Intensive Care of Erasme University Hospital (Brussels. Belgium). All consecutive patients admitted after in-hospital (IHCA) or out-of-hospital (OHCA) CA and surviving at least 24 h were included in an institutional database. We analysed data from all patients admitted from January 2009 to January 2013 who: a) were comatose (Glasgow Coma Scale [GCS] <9) on admission; and b) had haemodynamic variables available
Study population
During the study period, 221 patients were admitted after a CA; 11 died within 4 h after hospital admission without invasive haemodynamic monitoring, 31 received IABP/ECMO on admission and 9 had missing haemodynamic data, leaving a total of 170 patients for analysis. Among these patients (median age 63 years, 66% male, 59% OHCA), 106 (63%) had an unfavourable neurological outcome at 3 months. Patients with UO were older and more likely to have previous neurological diseases and liver cirrhosis
Discussion
In the present study, we investigated which haemodynamic variables in the early phase after ICU admission were associated with long-term neurological outcome in patients admitted to the ICU after cardiac arrest. High admission lactate levels and cSOFA scores, and lower lowest MAP and DAP values during the 6 h post-ICU admission were observed in patients with UO compared to those with favourable outcome. However, the lowest DAP value during the first six hours after ICU admission was the only
Author contributions
FA and FST conceived and designed the study; FA, FST and AMD selected the population. FA, FF, KD and AMD screened and collected data from the population; FST, SS and FF conducted the statistical analysis; FA, FST, JC, SS and JLV wrote the first draft of the manuscript; FST, JC, KD and JLV revised the text for intellectual content. All the authors read and approved the final text.
Conflicts of interest
None.
Funding
None.
References (26)
- et al.
Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke
Resuscitation
(2008) - et al.
Neurological prognostication after cardiac arrest and targeted temperature management 33°C versus 36°C: results from a randomised controlled clinical trial
Resuscitation
(2015) - et al.
Using the relationship between brain tissue regional saturation of oxygen and mean arterial pressure to determine the optimal mean arterial pressure in patients following cardiac arrest: a pilot proof-of-concept study
Resuscitation
(2016) - et al.
Hemodynamic targets during therapeutic hypothermia after cardiac arrest: a prospective observational study
Resuscitation
(2015) - et al.
The optimal hemodynamics management of post-cardiac arrest shock
Best Pract Res Clin Anaesthesiol
(2015) - et al.
SOFA score to assess the severity of the post-cardiac arrest syndrome
Resuscitation
(2016) - et al.
Association between blood pressure and outcomes in patients after cardiac arrest: a systematic review
Resuscitation
(2015) - et al.
Lower heart rate is associated with good one-year outcome in post-resuscitation patients
Resuscitation
(2018) - et al.
Association of hemodynamic variables with in-hospital mortality and favorable neurological outcomes in post-cardiac arrest care with targeted temperature management
Resuscitation
(2017) - et al.
Changes in left ventricular systolic and diastolic function on serial echocardiography after out-of-hospital cardiac arrest
Resuscitation
(2018)
Preliminary observations in systemic oxygen consumption during targeted temperature management after cardiac arrest
Resuscitation
Dynamic response of liquid-filled catheter systems for measurement of blood pressure: precision of measurements and reliability of the Pressure Recording Analytical Method with different disposable systems
J Crit Care
European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care
Intensive Care Med
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2023, Pediatrics and NeonatologyFactors affecting outcomes in patients with cardiac arrest who receive target temperature management: The multi-center TIMECARD registry
2022, Journal of the Formosan Medical AssociationCitation Excerpt :We noted that DBP also seems to play a role in PCA outcomes. Annoni et al. also reported a lower DBP of PCA in the first 6 h in the ICU was related to unfavorable neurologic outcomes, and our study extended the timing to the point of ROSC.28 Most perfusion of the coronary arteries occurs during the diastolic phase of the cardiac cycle, and the autoregulation system adjusts coronary flow during increasing workload or myocardial ischemia.
European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care
2021, ResuscitationCitation Excerpt :Whilst these studies showed that higher MAP targets with vasopressors are safe, and do not, for example, lead to cardiac arrhythmias, they failed to show any clear improvement in surrogate markers of brain injury with a higher MAP target. Nine observational studies found hypotension was associated with poor outcome.134–139,141,142 One study found time spent below optimal MAP (assessed by correlation between near-infrared spectroscopy and blood pressure) was associated with poor outcome;133 one study did not find low cardiac output to be associated with poor outcome,121 while the last study documented better outcomes among patients given fluids compared with vasopressors to increase MAP.140
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2021, Journal of Critical CareThe Effect of Chest Compression Location and Aortic Perfusion in a Traumatic Arrest Model
2021, Journal of Surgical ResearchCitation Excerpt :Although there was a trend toward improved ROSC, a larger study would be required to verify whether this trend is significant (our posthoc sample size calculation suggests more than twice as many animals would be required). The hemodynamic measures that most reliably predict ROSC and favorable clinical outcomes include ETCO2, AoD, and CPP36-40; Appendix A demonstrates that there was a trend toward higher values for all three of these variables in the LV group during the resuscitative period, especially during BLS, which may be contributing to the trend toward improved ROSC. Since the only difference between the historic No-SAAP control and the SAAP cohorts was the addition of the SAAP catheter, the lower-than-anticipated differences in ROSC and hemodynamics in the SAAP cohort might be due, in part, to the SAAP catheters providing enough afterload during compressions that the location of compressions becomes less important in general.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at https://doi.org/10.1016/j.resuscitation.2018.07.017.