RESUMO
PURPOSE: Fluid boluses (FB) are often used in post-cardiac arrest (CA) patients with haemodynamic instability. Although FB may improve cardiac output (CO) and mean arterial pressure (MAP), FB may also increase central venous pressure (CVP), reduce arterial PaO2, dilute haemoglobin and cause interstitial oedema. The aim of the present study was to investigate the net effect of FB administration on cerebral tissue oxygenation saturation (SctO2) in post-CA patients. METHODS: Pre-planned sub-study of the Neuroprotect post-CA trial (NCT02541591). Patients with anticipated fluid responsiveness based on stroke volume variation (SVV) or passive leg raising test were administered a FB of 500â¯ml plasma-lyte A (Baxter Healthcare) and underwent pre- and post-FB assessments of stroke volume, CO, MAP, CVP, haemoglobin, PaO2 and SctO2. RESULTS: 52 patients (mean age 64⯱â¯12â¯years, 75% male) received a total of 115 FB. Although administration of a FB resulted in a significant increase of stroke volume (63⯱â¯22 vs 67⯱â¯23â¯mL, pâ¯=â¯0.001), CO (4,2⯱â¯1,6 vs 4,4⯱â¯1,7 L/min, pâ¯=â¯0.001) and MAP (74,8⯱â¯13,2 vs 79,2⯱â¯12,9 mmHg, pâ¯=â¯0.004), it did not improve SctO2 (68.54⯱â¯6.99 vs 68.70⯱â¯6.80%, pâ¯=â¯0.49). Fluid bolus administration also resulted in a significant increase of CVP (10,0⯱â¯4,5 vs 10,7⯱â¯4,9 mmHg, pâ¯=â¯0.02), but did not affect PaO2 (99⯱â¯31 vs 94⯱â¯31â¯mmHg, pâ¯=â¯0.15) or haemoglobin concentrations (12,9⯱â¯2,1 vs 12,8⯱â¯2,2 g/dL, pâ¯=â¯0.10). In a multivariate model, FB-induced changes in CO (beta 0,77; pâ¯=â¯0.004) and in CVP (beta -0,23; pâ¯=â¯0.02) but not in MAP (beta 0,02; pâ¯=â¯0.18) predicted post-FB ΔSctO2. CONCLUSIONS: Despite improvements in CO and MAP, FB administration did not improve SctO2 in post-cardiac arrest patients.
Assuntos
Hidratação , Parada Cardíaca , Idoso , Pressão Arterial , Débito Cardíaco , Pressão Venosa Central , Feminino , Parada Cardíaca/terapia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Doenças Assintomáticas , Volume Sanguíneo/efeitos dos fármacos , Insuficiência Cardíaca , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Aldosterona/sangue , Bélgica , Pressão Sanguínea/efeitos dos fármacos , Determinação do Volume Sanguíneo/métodos , Doença Crônica , Estudos de Coortes , Dispneia/fisiopatologia , Impedância Elétrica , Feminino , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Albumina Sérica/análise , Sódio/sangue , Estatística como AssuntoRESUMO
AIM: In analogy with sepsis, current post-cardiac arrest (CA) guidelines recommend to target mean arterial pressure (MAP) above 65 mmHg and SVO2 above 70%. This is unsupported by mortality or cerebral perfusion data. The aim of this study was to explore the associations between MAP, SVO2, cerebral oxygenation and survival. METHODS: Prospective, observational study during therapeutic hypothermia (24h - 33 °C) in 82 post-CA patients monitored with near-infrared spectroscopy. RESULTS: Forty-three patients (52%) survived in CPC 1-2 until 180 days post-CA. The mean MAP range associated with maximal survival was 76-86 mmHg (OR 2.63, 95%CI [1.01; 6.88], p = 0.04). The mean SVO2 range associated with maximal survival was 67-72% (OR 8.23, 95%CI [2.07; 32.68], p = 0.001). In two separate multivariate models, a mean MAP (OR 3.72, 95% CI [1.11; 12.50], p=0.03) and a mean SVO2 (OR 10.32, 95% CI [2.03; 52.60], p = 0.001) in the optimal range persisted as independently associated with increased survival. Based on more than 1625000 data points, we found a strong linear relation between SVO2 (range 40-90%) and average cerebral saturation (R(2) 0.86) and between MAP and average cerebral saturation for MAP's between 45 and 101 mmHg (R(2) 0.83). Based on our hemodynamic model, the MAP and SVO2 ranges associated with optimal cerebral oxygenation were determined to be 87-101 mmHg and 70-75%. CONCLUSION: we showed that a MAP range between 76-86 mmHg and SVO2 range between 67% and 72% were associated with maximal survival. Optimal cerebral saturation was achieved with a MAP between 87-101 mmHg and a SVO2 between 70% and 75%. Prospective interventional studies are needed to investigate whether forcing MAP and SVO2 in the suggested range with additional pharmacological support would improve outcome.
Assuntos
Circulação Cerebrovascular/fisiologia , Parada Cardíaca/terapia , Hemodinâmica/fisiologia , Hipotermia Induzida/métodos , Adulto , Idoso , Pressão Arterial/fisiologia , Bélgica , Feminino , Parada Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Oxigênio/sangue , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho , Taxa de SobrevidaRESUMO
High-dose interleukin-2 (IL-2) therapy may cause acute myocarditis characterised by diffuse myocardial involvement and occasionally fulminant heart failure. Cardiac MRI (CMRI) provides a comprehensive assessment of myocardial function, inflammation and injury in a single examination and has shown value in the diagnosis of myocarditis. We report a case of a 54-year-old male with metastatic melanoma who developed acute severe myocarditis with fulminant heart failure after high-dose IL-2 therapy. CMRI using a combination of T(2) weighted imaging and T(1) weighted late post-gadolinium enhancement techniques played a key role in establishing the diagnosis. To our knowledge we present the first case report of the combined use of T(1) and T(2) weighted CMRI techniques to diagnose IL-2 induced myocarditis.