Body cooling increases survival after cardiac arrest


Induced body cooling (therapeutic hypothermia) after a sudden cardiac arrest increases patient survival and reduces cardiac arrhythmia complications, with no difference in outcomes between internal and external cooling, according to a local study presented at the recent Society for Emergency Medicine in Singapore Annual Scientific Meeting and International Resuscitation Science Symposium in Singapore.

Cooling, the deliberate reduction of core body temperature to a range of 32°C to 36°C, to decrease the body’s oxygen requirements helps to prevent a cascade of undesirable events leading to brain damage associated with cardiac arrest. This approach also gives surgeon more time to perform surgery before critical organ cells die from lack of oxygen.  

External cooling can be accomplished through water or cold air-forced circulating blankets, cooling helmet, icepacks or hydrogel-coated pads placed on the patient’s abdomen, back and thighs whereas internal cooling entails rapid infusion of chilled saline to an indwelling venous line placed percutaneously in the patient or through catheter-based technologies.

“In our study, there was no significant difference in terms of survival, neurological outcomes, and complications among patients receiving internal or external cooling following cardiac arrest,” said study author Dr. Sohil Pothiawala, associate consultant, Department of Emergency Medicine, Singapore General Hospital. “However, there was tighter temperature control with internal cooling.” [SEMS IReSS 2016, OR-1]

In the maintenance phase, for example, there was a lower risk of overcooling (odds ratio [OR], 0.25) and undercooling (OR, 0.12) in the internal cooling arm. Compared to normothermia, there was higher survival with internal cooling (OR, 3.361) and a lower risk of cardiac arrhythmia (OR, 0.182).

“That was in the subgroup analysis… patients who had cardiac arrest and sustained ROSC [return of spontaneous circulation] had better survival after internal cooling,” said Pothiawala.

The researchers sought to determine the survival-to-hospital discharge and neurological outcomes (assessed by Glasgow Pittsburg Score) of post-cardiac arrest patients in Singapore, randomized to internal cooling or external cooling.  The secondary objective was to compare survival outcomes for cooling (either method) versus normothermia.

“Internal cooling yielded better survival-to-hospital discharge outcomes, but the approach should be used in carefully selected patients,” said the authors.

The study adds to existing evidence that cooling after resuscitation may have beneficial effects on survival as against not cooling after a cardiac arrest.

In Singapore, sudden cardiac death accounts for about a third of deaths due to cardiac causes. The condition is far worse in the US where sudden cardiac arrest is the leading cause of death, with as little as 7 percent surviving the initial collapse. Even fewer of those whose hearts are restarted survive to leave the hospital due to irreversible brain damage.

Current guidelines by the American Heart Association (AHA) recommend body cooling after cardiac arrest to mitigate hypoxic injuries to the brain. [Circulation 2015;131:669-675]

Brain recovery after cardiac arrest is a major determinant of outcome in patients who survive cardiac resuscitation. Temperature elevation above normal following resuscitation could impair brain recoveryin these patients.

No Cognitive Benefit of Lower Temp After Cardiac Arrest


Cognitive function and quality of life are similar among cardiac arrest patients receiving a targeted temperature management of 33°C or 36°C, a new analysis shows.

The previously reported primary analysis of the Targeted Temperature Management (TTM) study showed that a lower temperature target did not reduce all-cause mortality, nor did it show benefit on a secondary composite endpoint of poor neurologic function or death at 180 days.

A new exploratory analysis looking at cognitive function and quality of life in the TTM trial using performance, observer-reported, and patient-reported measures still shows no difference between groups on the basis of target temperature.
The new results could be interpreted to mean that the way that hypothermia is typically administered is not effective, said lead author Tobias Cronberg, MD, PhD, associate professor, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden.

“But maybe we’re starting too late, maybe you have to cool for a longer period of time; or maybe you have to target specific categories of patients.”

The new analysis, the largest assessment to date of cognitive outcomes after cardiac arrest, was published online April 6 in JAMA Neurology.

Unique Approach

The TTM trial compared two temperature management regimens with a target of 33°C or 36°C after an out-of-hospital cardiac arrest in unconscious patients at 36 centers in Europe and Australia. Using outcome measures, including the Cerebral Performance Category (CPC) and modified Rankin scale (mRS), the study showed no difference in the two intervention groups.
However, these measures are “crude” and not designed to pick up mild cognitive impairment, said Dr Cronberg. “We wanted to try to do something more, try to investigate more, the real outcome of the patients, so we decided to use quite a new approach.”

That approach in the new analysis used four different perspectives: clinician-reported measures (CPC and mRS); patient-reported outcomes (Two Simple Questions) and quality of life (Medical Outcomes Study 36-Item Short Form Health Survey version 2 [SF-36v2]); performance measures (Mini-Mental State Examination [MMSE]); and relative-reported cognitive outcome (Informant Questionnaire of Cognitive Decline in the Elderly [IQCODE]).

In the IQCODE, a relative or close acquaintance is typically asked to compare the patient’s current status with that of 10 years before on a scale that can range from 26 to 130, with lower scores indicating better function and a score of 78 suggesting no change. In this study, however, informants were asked to compare post–cardiac arrest function to that before the arrest.

The study included 939 unconscious adults admitted to the hospital after an out-of-hospital cardiac arrest of presumed cardiac cause. Eligible patients were randomly assigned to management with 33°C or 36°C as the target temperature of cooling. In the 33°C group, 51.8% survived to follow-up compared with 52.8% of the 36°C group.

The analysis showed that at 6 months, more than 90% of survivors returned home and about 18% needed help with daily activities. Less than half returned to their previous state of employment.

No Group Differences

The median MMSE score for survivors was 28 for both groups (P = .61). From the Two Simple Questions assessments, there was no difference in the percentage of patients with an increased need for help in activities of daily living (18.8% for 33°C and 17.5% for the 36°C; P = .71), or those who thought they had made a complete recovery (66.9% vs 61.8%; P = .32).

There was also no between-group difference (P = .77) for survivors in the mean mental component summary score of the SF-36v2 (49.1 in the 33°C group vs 49.0 in the 36°C group). The mean physical component summary scores were 46.8 and 47.5 in the 33° and 36°C groups respectively (P = .44). Both the mental and physical summary scores were similar to population norms.

Although about 50% of patients or their relatives reported that the patient had cognitive problems, “still their quality of life is good,” commented Dr Cronberg.

But the study did pick up a difference in one measurement. While in the primary analysis, including nonsurvivors, the ICODE was identical in the intervention groups, there was a statistically significant difference of 1.2 IQCODE points favoring the 33°C group when analyzing survivors (P = .04). However, Dr Cronberg was very cautious about this finding.

Sensitive to Bias

“We found that it is very, very sensitive to bias,” he said. He noted that there was a higher mortality among patients in the 33°C group, “so it could be a survivor bias affecting this outcome.”

There were also other potentially confounding issues; for example, more patients in the lower temperature target group had less than 12 years of education, so they may not have recognized decline as easily as members of the other group.

“I think one should be very, very careful about overinterpreting that result,” said Dr Cronberg.

Another study from the same research group published online February 13 in Circulation carried out more extensive tests, including those for memory (Rivermead Behavioural Memory Test), executive function (Frontal Assessment Battery), and attention/mental speed (Symbol Digit Modalities Test), and found no difference between groups cooled to the two target temperatures.

But that’s not to say that hypothermia doesn’t benefit some patients, he cautioned. “We haven’t seen it yet in our analysis, but there may be more refined ways to select patients who need hypothermia treatment, and perhaps they need to be treated for several days,” said Dr Cronberg, adding that more research is needed to find such subgroups.

Earlier and Faster?

It is possible that initiating hypothermia earlier and faster is the way to go, he speculated. However, in other studies that started hypothermia earlier there was at least a trend toward negative effects that may be due to the cooling method.

“If you give a lot of cold fluids prehospital, patients tend to go into cardiogenic shock and it could be that those kinds of effects counterbalance the effects of hypothermia,” he said. “You need to cool quite rapidly to see a strong effect.”

Ideally, hypothermia management should be initiated before a cardiac arrest. “There’s no question about it from experimental evidence that if you cool somebody before a cardiac arrest then it’s really a very forceful treatment.”

One previously published study showed trans-nasal evaporative cooling during resuscitation is safe and feasible in humans and is associated with a significant improvement in the time intervals required to cool patients.

 In light of the new results indicating that outcomes for 33° and 36°C temperatures are similar, Dr. Cronberg anticipates that new guidelines from the International Liaison Committee on Resuscitation (ILCOR) later this year will recommend targeting either temperature.

However, in his own group, “we have decided to target 36° because it requires less cooling energy,” and is less invasive, he said. As well, cooling has been linked to risk for infection.

Dr Cronberg stressed that more than 90% of the survivors participated in the follow-up assessments at 6 months and more than 90% of the assessments were done in person rather than by telephone, as is often the case. Median time from the cardiac arrest to follow-up was 186 days.

“It’s amazing to see how willing the patients and their relatives have been,” said Dr. Cronberg. “I think that we have shown that such interviews are possible.”

Rates “Noteworthy”

These rates are “noteworthy” and the investigators should be “commended for their rigor and persistence” while conducting this study, said Venkatesh Aiyagari, MBBS, DM, Departments of Neurological Surgery and Neurology and Neuro-therapeutics, The University of Texas Southwestern Medical Center, Dallas, and Michael Diringer, MD, Departments of Neurology, Neurosurgery, Anesthesiology, and Occupational Therapy, Washington University School of Medicine, St Louis, Missouri, in an accompanying editorial.

Although none of the individual measures used in the study is particularly good at assessing cognitive outcome, the authors took the “unique” approach of combining the tests to highlight differences between what is reported by patients and observers, Dr Aiyagari and Dr Diringer write.

“As we move forward and focus on cognitive outcome, we must identify, refine, and validate more sensitive measures and apply them in a standardized format,” they said. “Currently, we know little about long-term cognitive outcomes and changes over time in patients after CA [cardiac arrest], and a longitudinal study of a cohort such as this would advance the field of resuscitation research.”

An important take-home message for neurologists who are often called upon to render an opinion on the prognosis of unconscious patients after cardiac arrest is that although cognitive changes are common, the overall long-term outcome of patients who survive to hospital discharge is quite good, said the editorial writers.

“Most of these patients are discharged home and report no problem with self-care, and a significant number are gainfully employed,” they note.

Near-Death Experiences May Be Explained By Heart-Brain Connection


near-death
At near-death, the brain sends messages to the heart and this flurry of mental activity may be the foundation of the near-death experience and also key to cardiac demise. Photo courtesy of 

The many experiences described by survivors of cardiac arrest — people revived even after their hearts stopped beating, sometimes for many minutes — include moving through a tunnel toward a white light, greeting relatives no longer alive, and overhearing conversations between family members in another room. A new study from the University of Michigan Medical School shows how the brain sends signals to the heart in the moments before death. It is this flurry of mental activity that is key to cardiac demise, the researchers say, and quite probably the foundation of near-death experiences as well.

“Reduction of oxygen or both oxygen and glucose during cardiac arrest can stimulate brain activity that is characteristic of conscious processing,” Dr. Jimo Borjigin, lead author of the study, stated in a press release. These current results combined with previous research provide a scientific framework for the near-death experiences reported by many cardiac arrest survivors.

Heart-Brain Connection

It’s a common assumption that if your heart stops, blood will stop flowing to the organs in your body and once the brain becomes starved of oxygen, death occurs. In this description, the heart is the lynchpin in the process. However, University of Michigan scientists say the brain may be performing the lead role in the process of death.

To better understand the neurobiology of death, the researchers induced asphyxiation in nine rats. Meanwhile, they monitored and examined the heart and brain simultaneously using an electrocardiomatrix, a technology developed in the Borjigin laboratory. These techniques uncovered mysteries.

Remarkably, the brain is much more active during the dying process than in the waking state, the researcers say. In the 30-second period after the animal’s hearts stopped beating, the researchers observed an immediate release of more than a dozen neurochemicals while high-frequency brainwaves called gamma oscillations increased. This activity seemed to trigger a connection between the brain and the heart. Following a steep fall in the heart rate, the researchers watched (via the electrocardiomatrix) as brain signals synchronized with the heart rhythm, beat for beat.

Borjigin believes a similar, elevated level of brain activity may also happen during the human experience of “near death” and it is this that gives rise to a heightened state of consciousness, including the visions experienced by survivors of cardiac arrest.

Importantly, when Borjigin and her colleagues blocked the signals flowing from the brain to the heart, they were able to delay, significantly, ventricular fibrillation — a quivering of the lower chambers of the heart that prevents it from pumping. If with drugs you could create a “blockade of the brain’s electrical connections to the heart during cardiac arrest,” Borjigin noted, it might be possible to “improve the chances of survival in cardiac arrest patients.”

Source: Li D, Mabrouk OS, Liu T, et al. Asphyxia-activated corticocardiac signaling accelerates onset of cardiac arrest. Proc Natl Acad Sci. 2015.

Life after death is real, concludes scientific study of 2,000 patients .


In the largest such study ever conducted, researchers have found evidence that consciousness continues even after brain activity has ceased. This evidence of life after death came from a study led by researchers from the University of Southampton and published in the journal Resuscitation.

death

“Contrary to perception, death is not a specific moment but a potentially reversible process that occurs after any severe illness or accident causes the heart, lungs and brain to cease functioning,” lead researcher Dr. Sam Parnia said. “If attempts are made to reverse this process, it is referred to as ‘cardiac arrest’; however, if these attempts do not succeed it is called ‘death.’ ”

Nearly 40 percent of those interviewed recalled experiencing some form of awareness after cardiac arrest (being pronounced clinically dead).

Wide diversity of near-death experiences

The AWARE (AWAreness during REsuscitation) study sought to use the scientific method to investigate the experiences typically described by the imprecise terms near-death experience (NDE) and out-of-body experience (OBE). Researchers interviewed 2,060 patients who had survived cardiac arrest from 15 hospitals across Austria, the United Kingdom and the United States.

“In this study we wanted to go beyond the emotionally charged yet poorly defined term of NDEs to explore objectively what happens when we die,” Dr. Parnia said.

The researchers found that 39 percent of cardiac arrest survivors interviewed described a sense that they had been “aware” following cardiac arrest. But many had no specific memories associated with the perception.

“This suggests more people may have mental activity initially but then lose their memories after recovery, either due to the effects of brain injury or sedative drugs on memory recall,” Dr. Parnia said.

Of those who reported a perception of awareness, only 2 percent described an experience consistent with the popular idea of an OBE, such as seeing or hearing events taking place around their bodies. Nine percent reported experiences consistent with the popular idea of an NDE, such as feelings of warmth or the presence of a light. Forty-six percent, however, reported experiences that were not consistent with either an OBE or an NDE, including fearful or persecutory experiences.

Clinical confirmation of out-of-body experience

Perhaps the study’s most significant finding was what may be the first-ever clinical confirmation of an OBE. In this case, a 57-year-old social worker accurately reported things that were happening around him after his brain activity had ceased.

“This is significant, since it has often been assumed that experiences in relation to death are likely hallucinations or illusions,” said Dr. Parnia said, “occurring either before the heart stops or after the heart has been successfully restarted, but not an experience corresponding with ‘real’ events when the heart isn’t beating.

“In this case, consciousness and awareness appeared to occur during a three-minute period when there was no heartbeat. This is paradoxical, since the brain typically ceases functioning within 20-30 seconds of the heart stopping and doesn’t resume again until the heart has been restarted. Furthermore, the detailed recollections of visual awareness in this case were consistent with verified events.”

The man’s memories were not only accurate but even helped the researchers place his experience in time.

“The man described everything that had happened in the room, but importantly, he heard two bleeps from a machine that makes a noise at three minute intervals. So we could time how long the [experience] lasted for,” Dr. Parnia said.

“He seemed very credible and everything that he said had happened to him had actually happened.”

“The researchers are to be congratulated on the completion of a fascinating study that will open the door to more extensive research into what happens when we die,” wrote Dr. Jerry Nolan, editor-in-chief of Resuscitation.

Sources:

http://www.independent.co.uk

http://www.sciencedaily.com

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Testosterone, estradiol levels could help predict sudden cardiac arrest


Assessing sex hormone levels could help identify people who are at an increased risk for sudden cardiac arrest, according to research published in Heart Rhythm.

Lower testosterone levels were observed in men who experienced sudden cardiac arrest and higher levels of estradiol increased likelihood in both men and women, researchers at Cedars-Sinai Heart Institute discovered.

“Because [sudden cardiac arrest] is usually fatal, we are constantly looking for ways to predict which patients are susceptible so we can concentrate on prevention,” Sumeet Chugh, MD, said in a press release. “If we wait until someone has a [sudden cardiac arrest], it is usually too late for treatment.”

Kumar Narayanan, MD, along with Chugh and colleagues, looked at patients from the ongoing Oregon Sudden Unexpected Death Study. The team identified 149 patients (median age, 64.1 years; 73.2% male) who experienced sudden cardiac arrest and matched them with controls (median age, 64.2 years; 72.5% male).

The researchers evaluated testosterone and estradiol levels based on blood samples, drawn at the time of sudden cardiac arrest in cases of an event or during a routine medical visit.

Median testosterone levels were significantly lower in men (4.4 ng/mL vs. 5.4 ng/mL; P=.01) in cases of sudden cardiac arrest vs. controls. Median estradiol levels were increased in men (68 pg/mL vs. 52 pg/mL; P<.001) and women (54 pg/mL vs. 36 pg/mL;P<.001) who had sudden cardiac arrest.

Higher testosterone levels were associated with lower sudden cardiac arrest risk in men only (OR=0.75; 95% CI, 0.58-0.96), based on multivariate analysis. Higher estradiol levels were associated with increased risk for sudden cardiac arrest in men (OR=2; 95% CI, 1.5-2.6) and women (OR=3.5; 95% CI, 1.9-6.4). In men, higher testosterone-to-estrogen ratio was associated with a lower likelihood of sudden cardiac arrest (OR=0.5; 95% CI, 0.4-0.7).

“This is the first time it has been reported that there is an association between sex hormone levels and [sudden cardiac arrest],” Chugh said. “While these findings need to be confirmed by other studies, they suggest that higher testosterone levels in men may offer protection from sudden cardiac arrest and lower levels of estrogen may protect both men and women.”

Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest.


BACKGROUND

Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. Our objective was to compare two target temperatures, both intended to prevent fever.

METHODS

In an international trial, we randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale.

RESULTS

In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.

CONCLUSIONS

In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.

Source: NEJM

 

Risks for Peri-Intubation Cardiac Arrest.


In a retrospective analysis, patients in shock were at higher risk for peri-intubation cardiac arrest, which usually had an initial rhythm of pulseless electrical activity.
Peri-intubation hypotension and even cardiac arrest are concerns in patients undergoing emergency resuscitation. To determine the incidence of peri-intubation cardiac arrest and factors associated with it, researchers retrospectively analyzed records for 410 adult patients who underwent rapid sequence intubation (RSI) at a single urban emergency department during 2007.

Peri-intubation cardiac arrest (defined as occurring within 60 minutes after initiation of airway management) was documented on the standardized data collection tool in 17 patients (4.2%), at a median 6 minutes after intubation. Nearly two thirds of cardiac arrests occurred within 10 minutes. Pulseless electrical activity was the initial arrest rhythm in most cases. Arrest was more common in patients with pre-intubation hypotension (12% vs. 3%) and in those with pre-intubation oxygen saturation (<92%).

In multivariate logistic regression analysis, higher pre-RSI shock index and body weight were independently associated with peri-intubation cardiac arrest. Although more than half of patients were initially resuscitated, peri-intubation cardiac arrest portended a 14-fold increase in the odds of in-hospital death.

COMMENT

The association of peri-intubation cardiac arrest with higher pre-intubation shock index, and the finding that nearly all cardiac arrest patients had pulseless electrical activity, highlights the precarious state of hypotensive critically ill patients, especially those with higher body mass index. We are subjecting these fragile patients to a combination of induction agents, airway manipulation, and, especially, positive pressure ventilation. The take-home message? Intubate earlier, if possible, before the patient deteriorates; optimize hemodynamic parameters with pressors, fluids, or blood; and carefully control mechanical ventilation to minimize ventilation pressures.

Source: NEJM.

Ultrasound Confirms Tube Position During Cardiopulmonary Resuscitation.


In this small study, the positive predictive value of ultrasound to confirm endotracheal tube placement during active compressions was 98.8%.
Confirming correct endotracheal tube (ETT) placement during cardiopulmonary resuscitation (CPR) can be challenging. In a prospective observational study, researchers in Taiwan assessed the accuracy of real-time tracheal ultrasonography in 89 cardiac arrest patients (age range, 24–98 years) receiving emergency intubation during CPR. Patients with severe neck trauma, neck tumors, or history of neck surgery (including tracheotomy) were excluded. The gold standard for correct ETT placement was defined as bilateral auscultated breath sounds with good capnography waveform and exhaled carbon dioxide >4 mm Hg after at least 5 breaths.

Three senior emergency medicine residents supervised by experienced faculty performed tracheal ultrasonography during and immediately after ETT insertion, with most scans taking 10 seconds or less. Observation of a single air-mucosa interface with comet-tail artifact confirmed tracheal placement. Seven patients (7.8%) had esophageal intubations. Sensitivity, specificity, and positive and negative predictive values of tracheal ultrasound for identifying ETT position were 100%, 86%, 99%, and 100%, respectively.

COMMENT

Aspiration devices are the current standard for confirmation of tracheal tube placement during CPR when end-tidal CO2 is not detectable. Ultrasound shows promise in this setting, but the failure to identify 1 in 7 esophageal intubations is concerning. The key to establishing the value of ultrasound for tracheal tube confirmation lies in demonstration of its ability to detect 100% of esophageal intubations. We are not there yet.

Source: NEJM

Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest.


A Randomized Clinical Trial

 

Importance  Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.

Objective  To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.

Design, Setting, and Participants  Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).

Interventions  Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n = 130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n = 138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n = 76) or saline placebo (control group, n = 73).

Main Outcomes and Measures  Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2.

Results  Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P = .005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P = .02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.

Conclusion and Relevance  Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.

Source: JAMA

Paralyzing Comatose Cardiac Arrest Survivors Improves Outcomes.


Neuromuscular blockade for at least 24 hours improved in-hospital survival rate.
The 2010 American Heart Association guidelines recommend limiting neuromuscular blockade (NMB) in patients with return of spontaneous circulation (ROSC) because it could be harmful. However, NMB is often used to prevent shivering in post–cardiac arrest patients receiving therapeutic hypothermia. Researchers performed a post-hoc analysis of a prospective, observational study of comatose adults with nontraumatic out-of-hospital cardiac arrest who had sustained ROSC (palpable pulses for ≥20 minutes) and were transported to four centers over a 9-month period.

Of 111 patients, 18 received NMB for at least 24 hours after ROSC (sustained NMB), 59 received NMB for less than 24 hours, and 34 received no NMB. In-hospital survival was higher in patients who received NMB at any point than in those who received no NMB (52% vs. 35%). Patients who received sustained NMB were more likely to survive than the other two groups combined (78% vs. 41%). Fifty percent of those who received sustained NMB and 28% of the other two groups had favorable neurologic outcomes (not a significant difference). The sustained-NMB group had similar prognostic scores but shorter time from collapse to ROSC, higher baseline blood pH, and lower incidence of chronic obstructive pulmonary disease than the other two groups combined. Multivariable analysis showed that sustained NMB was independently associated with survival (adjusted odds ratio, 7.23) and improvement in lactic acidosis.

The authors postulate that NMB reduces metabolic demand and global oxygen consumption, improves pulmonary gas exchange, and prevents ventilator dyssynchrony, thereby protecting against episodic rises in intracranial pressure.

COMMENT

Although some studies have suggested that long-term neuromuscular blockade may lead to critical illness, polyneuropathy, or generalized muscle weakness, this study suggests it may have benefit in post–cardiac arrest patients. A note of caution, however: Be sure that any patient with a chance of awareness is adequately sedated before paralysis!

 

 

 

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