Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients
ABSTRACT Early, effective lactate clearance has been shown to be associated with improved mortality in patients with trauma, burns, and sepsis. We investigated whether early, high lactate clearance was associated with reduced mortality in post-cardiac arrest patients.
We performed a retrospective analysis of post-cardiac arrest patients in an urban emergency department. Inclusion criteria included pre-hospital cardiac arrest patients over the age of 18. Exclusion criteria were traumatic arrest, successful resuscitation prior to the arrival of emergency medical services, and cardiac arrest in the presence of pre-hospital providers. Primary endpoints consisted of survival to 24h and survival to hospital discharge.
A total of 79 patients were analyzed with a mean age of 64+/-17 and mean APACHE II score of 37.7+/-5. Of the 79 patients, 27 (34%) died within 24h and 66 (84%) died during the hospital course. The mean initial lactate level for the overall group was 15+/-5.2mmol/dl with a mean lactate of 14.4+/-5.1mmol/dl in the survivors and 16+/-5.3mmol/dl in the non-survivors (p>0.05). Lactate clearance at both 6 and 12h was significantly higher for both 24-h and overall in-hospital survival (p<0.05). A multivariable analysis showed that high lactate clearance at 12h was predictive of 24-h survival (p<0.05).
Early, effective lactate clearance is associated with decreased early and overall in-hospital mortality in post-cardiac arrest patients. These findings suggest that post-arrest tissue hypo-perfusion plays in an important role in early as well as overall mortality.
Critical Care Medicine 08/2014; 42(8):1942-1943. DOI:10.1097/CCM.0000000000000369 · 6.15 Impact Factor
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ABSTRACT: Hemodynamic monitoring is widely used in critical care; however, the impact of such intervention in patients with acute brain injury (ABI) remains unclear. Using PubMed, a systematic review was performed (1966-August 2013), and 118 studies were included. Data were extracted using the PICO approach. The evidence was classified, and recommendations were developed according to the GRADE system. Electrocardiography and invasive monitoring of arterial blood pressure should be the minimal hemodynamic monitoring required in unstable or at-risk patients in the intensive care unit. Advanced hemodynamic monitoring (i.e., assessment of preload, afterload, cardiac output, and global systemic perfusion) could help establish goals that take into account cerebral blood flow and oxygenation, which vary depending on diagnosis and disease stage. Choice of techniques for assessing preload, afterload, cardiac output, and global systemic perfusion should be guided by specific evidence and local expertise. Hemodynamic monitoring is important and has specific indications among ABI patients. Further data are necessary to understand its potential for therapeutic interventions and prognostication.Neurocritical Care 09/2014; 21(S2). DOI:10.1007/s12028-014-0033-5 · 3.04 Impact Factor
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ABSTRACT: The estimated survival rate of 8-10% after out-of-hospital cardiac arrest (OHCA) remains dismal. Few studies have addressed predictors of functional neurological outcome after successful resuscitation. The objective of the study was to identify variables associated with favorable neurological outcomes, defined by a Glasgow Coma Scale (GCS) of 14 or 15, after OHCA. We used a propensity analysis and classification and regression tree (CART) model of 184 OHCA patients surviving to hospital admission at a cardiac arrest receiving center in Los Angeles County from 2008 – 2013. Forty-three patients (23%) had a favorable outcome; median age was 65 (IQR 54-76); 98 (53%) were male. Sixty-six (36%) presented with a shockable rhythm. The majority were witnessed, either by a civilian (n=115, 63%) or a paramedic (n=25, 14%). Bystander CPR was performed on 84 (46%); median dose of epinephrine was 2 mg (IQR 1-3 mg). Median time to return of spontaneous circulation was 21 minutes (IQR 16-29); median lactate was 5.2 (IQR 2.8-9.2). Lower epinephrine doses (<1.5 mg) and lactate < 5 mmol/L were predictive of a normal GCS; 90.7% sensitivity (95%CI 76.9-96.9), 47.5% specificity (95%CI 39.1-56.1), PPV 34.5% (95%CI 31.6-46.1), NPV 94.4% (95%CI 85.5-98.2), and AUC of 0.89. Propensity-score adjusted logistic regression model demonstrated that receiving < 1.5 mg of epinephrine was associated with a favorable neurological outcome (OR=3.3, 95%CI 1.1-10, p=0.04). In conclusion, for patients surviving to hospital admission, a good neurological outcome was associated with having received < 1.5 mg of epinephrine and a lactate < 5 mmol/L.The American Journal of Cardiology 10/2014; 114(7). DOI:10.1016/j.amjcard.2014.06.031 · 3.43 Impact Factor