Elsevier

Resuscitation

Volume 130, September 2018, Pages 167-173
Resuscitation

Clinical paper
The impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients

https://doi.org/10.1016/j.resuscitation.2018.07.017Get rights and content

Abstract

Aim

Which haemodynamic variable is the best predictor of neurological outcome remains unclear. We investigated the association of several haemodynamic variables with neurological outcome in CA patients.

Methods

Retrospective analysis of adult comatose survivors of CA admitted to the intensive care unit (ICU) of a University Hospital. Exclusion criteria were early death due to withdrawal of care, missing haemodynamic data and use of intra-aortic balloon pump or extracorporeal membrane oxygenation. We retrieved CA characteristics; lactate concentration and cardiovascular sequential organ failure assessment (cSOFA) score on admission; systolic (SAP), diastolic (DAP), mean arterial pressure (MAP), and the use of vasopressors and inotropic agents during the first 6 h of ICU stay. Unfavourable neurological outcome (UO) was defined as a 3-month cerebral performance category score of 3–5.

Results

Among the 170 patients (median age 63 years, 67% male, 60% out-of-hospital CA), 106 (63%) had UO. Admission lactate was higher in patients with UO than in those with favourable neurological outcome (4.0[2.4–7.3] vs. 2.5[1.4–6.0] mEq/L; p = 0.003) as was the cSOFA (3 [[1], [2], [3], [4]] vs. 2[0–3]; p = 0.007). The lowest DAP during the first 6 h after ICU admission was significantly lower in patients with unfavourable neurological outcome, notably in patients with high cSOFA scores. In multivariable analysis, high adrenaline doses and the lowest value of DAP during the first 6 h after ICU admission was significantly associated with unfavourable neurological outcome.

Conclusions

In CA patients admitted to the ICU, low DAP during the first 6 h is an independent predictor of unfavourable neurological outcome at 3 months.

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.

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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.

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