Oxygen metabolism after cardiac arrest: Patterns and associations with survival.

Aim: Whether changes in oxygen metabolism, as measured by oxygen consumption (VO2), carbon dioxide production (VCO2) and the respiratory exchange ratio (RER), are associated with survival after cardiac arrest is poorly understood. In this prospective observational study, we investigated the association between VO2, VCO2, and RER in the initial 12 and 24 h after return of spontaneous circulation (ROSC) and survival to hospital discharge. Methods: Adults with ROSC after cardiac arrest, admitted to the intensive care unit, requiring mechanical ventilation and treated with targeted temperature management were included. VO2 and VCO2 were measured continuously for 24 h after ROSC, using a noninvasive anesthesia monitor. Area under the curve for VO2, VCO2 & RER was calculated using all available values over 12 and 24 h after ROSC. Using logistic regression, we evaluated the relationship between these metabolic variables and survival to hospital discharge. Analyses were adjusted for temperature, vasopressors, and neuromuscular blockade. Results: Sixty four patients were included. Mean age was 64 ± 16 years, and 59% were women. There was no significant association between the area under the curve of VO2 or VCO2 and survival. A higher RER in the initial 12 h was associated with better survival (aOR = 3.97, 95% CI [1.01,15.6], p = 0.048). Survival was lower in those with median RER < 0.7 in the initial 12 h compared with those with a median RER ≥ 0.7 (25% vs 67%, p = 0.011). Conclusion: Higher RER in the initial 12 h was associated with survival after cardiac arrest. The etiology of unusually low RERs in this patient population remains unclear.

Kidney-specific biomarkers for predicting acute kidney injury following cardiac arrest.

AIM: To evaluate the performance of kidney-specific biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and cystatin-C) in early detection of acute kidney injury (AKI) following cardiac arrest (CA) when compared to serum creatinine. METHODS: Adult CA patients who had kidney-specific biomarkers of AKI collected within 12 h of return of spontaneous circulation (ROSC) were included. The association between renal biomarker levels post-ROSC and the development of KDIGO stage III AKI within 7 days of enrollment were assessed as well as their predictive value of future AKI development, neurological outcomes, and survival to discharge. RESULTS: Of 153 patients, 54 (35%) developed stage III AKI within 7 days, and 98 (64%) died prior to hospital discharge. Patients who developed stage III AKI, compared to those who did not, had higher median levels of creatinine, NGAL, and cystatin-C (p < 0.001 for all). There was no statistically significant difference in KIM-1 between groups. No biomarker outperformed creatinine in the ability to predict stage III AKI, neurological outcomes, or survival outcomes (p > 0.05 for all). However, NGAL, cystatin-C, and creatinine all performed better than KIM-1 in their ability to predict AKI development (p < 0.01 for all). CONCLUSION: In post-CA patients, creatinine, NGAL, and cystatin-C (but not KIM-1) measured shortly after ROSC were higher in patients who subsequently developed AKI. No biomarker was statistically superior to creatinine on its own for predicting the development of post-arrest AKI.

Acute respiratory distress syndrome after in-hospital cardiac arrest.

OBJECTIVE: Acute respiratory distress syndrome (ARDS) after out-of-hospital cardiac arrest is common and associated with worse outcomes. In the hospital setting, there are many potential risk factors for post-arrest ARDS, such as aspiration, sepsis, and shock. ARDS after in-hospital cardiac arrest (IHCA) has not been characterized. METHODS: We performed a single-center retrospective study of adult patients admitted to the hospital between 2014-2018 who suffered an IHCA, achieved return of spontaneous circulation (ROSC), and were either already intubated at the time of arrest or within 2 hours of ROSC. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days following ROSC. Outcomes included alive-and-ventilator free days across 28 days, hospital length-of-stay, hospital mortality, and hospital disposition. RESULTS: Of 203 patients included, 146 (71.9%) developed ARDS. In unadjusted analysis, patients with ARDS had fewer alive-and-ventilator-free days over 28 days with a median of 1 (IQR: 0, 21) day, compared to 18 (IQR: 0, 25) days in patients without ARDS (p = 0.03). However, this association was not significant after multivariate adjustment. There was also a non-significant longer hospital length-of-stay (15 [IQR: 7, 26] vs 10 [IQR: 7, 22] days, p = 0.25; median adjusted increase in ARDS patients: 3 [95% CI: -2 to 8] days, p = 0.27) and higher hospital mortality (53% vs 44%, p = 0.26; aOR 1.6 [95% CI: 0.8-2.9], p = 0.17) in the ARDS group. CONCLUSION: Among IHCA patients, almost three-quarters developed ARDS within 3 days of ROSC. As in out of hospital cardiac arrest, post-IHCA ARDS is common.

Thiamine Supplementation in Patients With Alcohol Use Disorder Presenting With Acute Critical Illness : A Nationwide Retrospective Observational Study.

BACKGROUND: Thiamine supplementation is recommended for patients with alcohol use disorder (AUD). The authors hypothesize that critically ill patients with AUD are commonly not given thiamine supplementation. OBJECTIVE: To describe thiamine supplementation incidence in patients with AUD and various critical illnesses (alcohol withdrawal, septic shock, traumatic brain injury [TBI], and diabetic ketoacidosis [DKA]) in the United States. DESIGN: Retrospective observational study. SETTING: Cerner Health Facts database. PATIENTS: Adult patients with a diagnosis of AUD who were admitted to the intensive care unit with alcohol withdrawal, septic shock, TBI, or DKA between 2010 and 2017. MEASUREMENTS: Incidence and predicted probability of thiamine supplementation in alcohol withdrawal and other critical illnesses. RESULTS: The study included 14 998 patients with AUD. Mean age was 52.2 years, 77% of participants were male, and in-hospital mortality was 9%. Overall, 7689 patients (51%) received thiamine supplementation. The incidence of thiamine supplementation was 59% for alcohol withdrawal, 26% for septic shock, 41% for TBI, and 24% for DKA. Most of those receiving thiamine (n = 3957 [52%]) received it within 12 hours of presentation in the emergency department. The predominant route of thiamine administration was enteral (n = 3119 [41%]). LIMITATION: Specific dosing and duration were not completely captured. CONCLUSION: Thiamine supplementation was not provided to almost half of all patients with AUD, raising a quality-of-care issue for this cohort. Supplementation was numerically less frequent in patients with septic shock, DKA, or TBI than in those with alcohol withdrawal. These data will be important for the design of quality improvement studies in critically ill patients with AUD. PRIMARY FUNDING SOURCE: National Institutes of Health.

Lactate and hypotension as predictors of mortality after in-hospital cardiac arrest.

AIM: Guidance on post-cardiac arrest prognostication is largely based on data from out-of-hospital cardiac arrest (OHCA), despite clear differences between the OHCA and in-hospital cardiac arrest (IHCA) populations. Early prediction of mortality after IHCA would be useful to help make decisions about post-arrest care. We evaluated the ability of lactate and need for vasopressors after IHCA to predict hospital mortality. METHODS: Single center retrospective observational study of adult IHCA patients who achieved sustained return of spontaneous circulation (ROSC), required mechanical ventilation peri-arrest and had a lactate checked within 2 h after ROSC. We evaluated the association of post-ROSC lactate and need for vasopressors with mortality using multivariate logistic regression. RESULTS: A total of 364 patients were included. Patients who received vasopressors within 3 h after ROSC had significantly higher mortality compared to patients who did not receive vasopressors (58% vs. 43%, p = 0.03). Elevated lactate level was associated with mortality (44% if lactate <5 mmol/L, 58% if lactate 5-10 mmol/L, and 73% if lactate >10 mmol/L, p < 0.01). A multivariable model with lactate group and post-ROSC vasopressor use as predictors demonstrated moderate discrimination (AUC 0.64 [95%CI:0.59-0.70]). Including other variables, the most parsimonious model included lactate, age, body mass index, race, and history of arrhythmia, cancer and/or liver disease (AUC 0.70 [95% CI: 0.64-0.75]). CONCLUSION: Post-ROSC lactate and need for vasopressors may be helpful in stratifying mortality risk in patients requiring mechanical ventilation after IHCA.

Prognostication with point-of-care echocardiography during cardiac arrest: A systematic review.

AIM: To conduct a prognostic factor systematic review on point-of-care echocardiography during cardiac arrest to predict clinical outcomes in adults with non-traumatic cardiac arrest in any setting. METHODS: We conducted this review per PRISMA guidelines and registered with PROSPERO (ID pending). We searched Medline, EMBASE, Web of Science, CINAHL, and the Cochrane Library on September 6, 2019. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality in Prognosis Studies (QUIPS) template. We estimated prognostic test performance (sensitivity and specificity) and measures of association (odds ratio). Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology evaluated the certainty of evidence. RESULTS: In total, 15 studies were included. We found wide variation across studies in the definition of 'cardiac motion' and timing of sonographic assessment. Most studies were hindered by high risks of bias from prognostic factor measurement, outcome measurement, and lack of adjustment for other prognostic factors. Ultimately, heterogeneity and risk of bias precluded meta-analyses. We tabulated ranges of prognostic test performance and measures of association for 5 different combinations of definitions of 'cardiac motion' and sonographic timing, as well as other miscellaneous sonographic findings. Overall certainty of this evidence is very low. CONCLUSIONS: The evidence for using point-of-care echocardiography as a prognostic tool for clinical outcomes during cardiac arrest is of very low certainty and is hampered by multiple risks of bias. No sonographic finding had sufficient and/or consistent sensitivity for any clinical outcome to be used as sole criterion to terminate resuscitation.

Vasopressors during adult cardiac arrest: A systematic review and meta-analysis.

AIM: To systematically review the literature on the use of vasopressors during adult cardiac arrest to inform an update of international guidelines. METHODS: PRISMA guidelines were followed. We searched Medline, Embase, Web of Science, CINAHL, and the Cochrane Library for controlled trials and observational studies. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed the risk of bias for individual studies. Certainty of evidence was evaluated using GRADE for controlled trials and meta-analyses were performed when at least two studies could be pooled. RESULTS: We included 15 controlled trials and 67 observational studies. The majority of studies included out-of-hospital cardiac arrest only. Meta-analyses were performed for two controlled trials comparing epinephrine to placebo, three comparing vasopressin to epinephrine, and three comparing epinephrine plus vasopressin to epinephrine only. All controlled trials ranged between low to some concern in risk of bias. The certainty of evidence ranged from very low to high. Risk of bias for observational studies was generally critical or serious, largely due to confounding and selection bias. CONCLUSIONS: Controlled trial data suggest that epinephrine improves return of spontaneous circulation, survival to hospital discharge, and 3-month survival in out-of-hospital cardiac arrest. The improvement in short-term outcomes appeared more pronounced for non-shockable rhythms. Differences in long-term neurological outcome did not reach statistical significance, although there was a signal toward improved outcomes. Controlled trial data indicated no benefit from vasopressin with or without epinephrine compared to epinephrine only.