Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest

Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
Resuscitation (Impact Factor: 3.96). 02/2009; 80(4):418-24. DOI: 10.1016/j.resuscitation.2008.12.015
Source: PubMed

ABSTRACT Comatose survivors of out-of-hospital cardiac arrest (OHCA) have high in-hospital mortality due to a complex pathophysiology that includes cardiovascular dysfunction, inflammation, coagulopathy, brain injury and persistence of the precipitating pathology. Therapeutic hypothermia (TH) is the only intervention that has been shown to improve outcomes in this patient population. Due to the similarities between the post-cardiac arrest state and severe sepsis, it has been postulated that early goal-directed hemodyamic optimization (EGDHO) combined with TH would improve outcome of comatose cardiac arrest survivors.
We examined the feasibility of establishing an integrated post-cardiac arrest resuscitation (PCAR) algorithm combining TH and EGDHO within 6h of emergency department (ED) presentation.
In May, 2005 we began prospectively identifying comatose (Glasgow Motor Score<6) survivors of OHCA treated with our PCAR protocol. The PCAR patients were compared to matched historic controls from a cardiac arrest database maintained at our institution.
Between May, 2005 and January, 2008, 18/20 (90%) eligible patients were enrolled in the PCAR protocol. They were compared to historic controls from 2001 to 2005, during which time 18 patients met inclusion criteria for the PCAR protocol. Mean time from initiation of TH to target temperature (33 degrees C) was 2.8h (range 0.8-23.2; SD=h); 78% (14/18) had interventions based upon EGDHO parameters; 72% (13/18) of patients achieved their EGDHO goals within 6h of return of spontaneous circulation (ROSC). Mortality for historic controls who qualified for the PCAR protocol was 78% (14/18); mortality for those treated with the PCAR protocol was 50% (9/18) (p=0.15).
In patients with ROSC after OHCA, EGDHO and TH can be implemented simultaneously.

Download full-text


Available from: Julie Hylton, Aug 10, 2015
1 Follower
  • Source
    • "Other treatments, such as early hemodynamic optimization [1], controlled reoxygenation [4], supportive care, and disease-specific interventions guided by the patients' conditions, have potential benefit for patients with post– cardiac arrest syndrome. One possible benefit of the above treatments is the prevention of an increase in the oxygen debt and a decrease in the systemic and cerebral metabolic rates of oxygen consumption [5]. The restoration of blood perfusion to vital organs and the capacity for oxygen delivery are strongly associated with ischemia and reperfusion injuries during cardiac arrest and ⁎ Members listed at end of paper. "
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The hemoglobin (Hb) level is an essential determinant of oxygen delivery. The restoration of blood perfusion to vital organs and the capacity for oxygen delivery may be associated with ischemia and reperfusion injuries during cardiac arrest and after cardiac arrest. However, whether the Hb level is associated with neurologic outcome in post-cardiac arrest patients remains unclear. METHODS: Emergency medical service information and clinical demographics were compiled for witnessed out-of-hospital cardiac arrest patients with coma after the restoration of spontaneous circulation. The study end point was defined as a favorable neurologic outcome at 28 days. We evaluated the relationship between the Hb level at the time of hospital arrival and the neurologic outcome using univariate analyses and a multivariate logistic regression analysis. RESULTS: There were 137 witnessed cardiac arrest patients: 49 (35.7%) survived and 34 (24.8%) achieved a favorable neurologic outcome. Univariate analyses showed that the favorable outcome group was characterized as having a higher Hb level, a younger age, a higher percentage of male patients, and ventricular fibrillation as the initial cardiac rhythm. In a multivariate analysis adjusting for potential confounding factors, the Hb level at the time of hospital arrival (odds ratio, 1.26; 95% confidence interval, 1.00-1.58) was an independent predictor of a favorable neurologic outcome. CONCLUSION: A higher Hb level at the time of hospital arrival was associated with a favorable short-term neurologic outcome among post-cardiac arrest patients with a presumed cardiac etiology.
    The American journal of emergency medicine 01/2012; 30(5):770-774. DOI:10.1016/j.ajem.2011.03.031. · 1.15 Impact Factor
  • Source
    Notfall 11/2010; 13(7):559-620. DOI:10.1007/s10049-010-1370-3 · 0.32 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Der Herz-Kreislauf-Stillstand mit kardiopulmonaler Reanimation bewirkt ein Ischämie-Reperfusion-Syndrom des gesamten Körpers. Einerseits liegt eine lokalisierte Schädigung besonders empfindlicher Organe wie des Gehirns und des Herzens vor; andererseits zeigen sich auch systemische Folgen. An erster Stelle steht hier die generalisierte Aktivierung von Entzündungsreaktionen. Damit gleicht das Krankheitsbild in zahlreichen Aspekten der Sepsis. Die systemische Entzündung verstärkt die Organschäden durch Störungen der Makro- und Mikrozirkulation, durch Stoffwechseldysbalancen sowie infolge direkter leukozytenvermittelter Gewebszerstörung. Der vorliegende Beitrag gibt einen Überblick über die Rolle der Entzündung nach Herz-Kreislauf-Stillstand und stellt ausführlich die zugrunde liegenden Mechanismen, ihr klinisches Erscheinungsbild und mögliche therapeutische Ansätze vor.
    Der Anaesthesist 05/2012; 61(5). DOI:10.1007/s00101-012-2002-8 · 0.74 Impact Factor
Show more