Arterial blood pressure during targeted temperature management after out-of-hospital cardiac arrest and association with brain injury and long-term cognitive function

Abstract

Objectives:

During targeted temperature management after out-of-hospital cardiac arrest infusion of vasoactive drugs is often needed to ensure cerebral perfusion pressure. This study investigated mean arterial pressure after out-of-hospital cardiac arrest and the association with brain injury and long-term cognitive function.

Methods:

Post-hoc analysis of patients surviving at least 48 hours in the biobank substudy of the targeted temperature management trial with available blood pressure data. Patients were stratified in three groups according to mean arterial pressure during targeted temperature management (4–28 hours after admission; <70 mmHg, 70–80 mmHg, >80 mmHg). A biomarker of brain injury, neuron-specific enolase, was measured and impaired cognitive function was defined as a mini-mental state examination score below 27 in 6-month survivors.

Results:

Of the 657 patients included in the present analysis, 154 (23%) had mean arterial pressure less than 70 mmHg, 288 (44%) had mean arterial pressure between 70 and 80 mmHg and 215 (33%) had mean arterial pressure greater than 80 mmHg. There were no statistically significant differences in survival (P=0.35) or neuron-specific enolase levels (P=0.12) between the groups. The level of target temperature did not statistically significantly interact with mean arterial pressure regarding neuron-specific enolase (P_{interaction_MAP*TTM}=0.58). In the subgroup of survivors with impaired cognitive function (n=132) (35%) mean arterial pressure during targeted temperature management was significantly higher (P_group=0.03).

Conclusions:

In a large cohort of comatose out-of-hospital cardiac arrest patients, low mean arterial pressure during targeted temperature management was not associated with higher neuron-specific enolase regardless of the level of target temperature (33°C or 36°C for 24 hours). In survivors with impaired cognitive function, mean arterial pressure during targeted temperature management was significantly higher.

Keywords

Out-of-hospital cardiac arrest post-resuscitation syndrome blood pressure brain injuries cerebral autoregulation cerebral blood flow

Get full access to this article

View all access options for this article.

References

Laver

Farrow

Turner

, et al. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 2004; 30: 2126–2128.

Nolan

Soar

Cariou

, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines for post-resuscitation care 2015: section 5 of the European Resuscitation Council guidelines for resuscitation 2015. Resuscitation 2015; 95: 202–222.

Callaway

Donnino

Fink

, et al. Part 8: Post-cardiac arrest care: 2015. American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132: S465–S482.

Sundgreen

Larsen

Herzog

, et al. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke 2001; 32: 128–132.

Nishizawa

Kudoh

. Cerebral autoregulation is impaired in patients resuscitated after cardiac arrest. Acta Anaesthesiol Scand 1996; 40: 1149–1153.

Buunk

van der Hoeven

Meinders

. Cerebral blood flow after cardiac arrest. Neth J Med 2000; 57: 106–112.

Russo

James

Hibbert

, et al. Impact of mean arterial pressure on clinical outcomes in comatose survivors of out-of-hospital cardiac arrest: insights from the University of Ottawa Heart Institute Regional Cardiac Arrest Registry (CAPITAL-CARe). Resuscitation 2017; 113: 27–32.

Kilgannon

Roberts

Jones

, et al. Arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest*. Crit Care Med 2014; 42: 2083–2091.

van den

Brule JM

Vinke

van Loon

, et al. Middle cerebral artery flow, the critical closing pressure, and the optimal mean arterial pressure in comatose cardiac arrest survivors – an observational study. Resuscitation 2017; 110: 85–89.

10.

Jakkula

Pettila

Skrifvars

, et al. Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial. Intensive Care Med 2018; 44: 2091–2101.

11.

Nielsen

Wetterslev

Cronberg

, et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 2013; 369: 2197–2206.

12.

Nielsen

Winkel

Cronberg

, et al. Detailed statistical analysis plan for the target temperature management after out-of-hospital cardiac arrest trial. Trials 2013; 14: 300.

13.

Nielsen

Wetterslev

al-Subaie

, et al. Target temperature management after out-of-hospital cardiac arrest – a randomized, parallel-group, assessor-blinded clinical trial–rationale and design. Am Heart J 2012; 163: 541–548.

14.

Stammet

Collignon

Hassager

, et al. Neuron-specific enolase as a predictor of death or poor neurological outcome after out-of-hospital cardiac arrest and targeted temperature management at 33 degrees C and 36 degrees C. J Am Coll Cardiol 2015; 65: 2104–2114.

15.

Cronberg

Lilja

Horn

, et al. Neurologic function and health-related quality of life in patients following targeted temperature management at 33 degrees C vs 36 degrees C after out-of-hospital cardiac arrest: a randomized clinical trial. JAMA Neurol 2015; 72: 634–641.

16.

Dragancea

Rundgren

Englund

, et al. The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 2013; 84: 337–342.

17.

Langhelle

Nolan

Herlitz

, et al. Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: the Utstein style. Resuscitation 2005; 66: 271–283.

18.

Grand

Hassager

Winther-Jensen

, et al. Mean arterial pressure during targeted temperature management and renal function after out-of-hospital cardiac arrest. J Crit Care 2018; 50: 234–241.

19.

Bro-Jeppesen

Annborn

Hassager

, et al. Hemodynamics and vasopressor support during targeted temperature management at 33 degrees C versus 36 degrees C after out-of-hospital cardiac arrest: a post hoc study of the target temperature management trial*. Crit Care Med 2015; 43: 318–327.

20.

Wiberg

Hassager

Stammet

, et al. Single versus serial measurements of neuron-specific enolase and prediction of poor neurological outcome in persistently unconscious patients after out-of-hospital cardiac arrest – a TTM Trial Substudy. PLoS One 2017; 12: e0168894.

21.

Lilja

Nielsen

Friberg

, et al. Cognitive function after cardiac arrest and temperature management; rationale and description of a sub-study in the Target Temperature Management trial. BMC Cardiovasc Disord 2013; 13: 85.

22.

Haywood

Whitehead

Nadkarni

, et al. COSCA (core outcome set for cardiac arrest) in adults: an advisory statement from the International Liaison Committee on Resuscitation. Resuscitation 2018; 127: 147–163.

23.

Folstein

McHugh

. Cognitive defect in medical illness. Ann Intern Med 1977; 86: 827–828.

24.

Jorm

Jacomb

. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol Med 1989; 19: 1015–1022.

25.

Ware JE Jr and Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30: 473–483.

26.

Laurikkala

Wilkman

Pettila

, et al. Mean arterial pressure and vasopressor load after out-of-hospital cardiac arrest: associations with one-year neurologic outcome. Resuscitation 2016; 105: 116–122.

27.

Torgersen

Meichtry

Schmittinger

, et al. Haemodynamic variables and functional outcome in hypothermic patients following out-of-hospital cardiac arrest. Resuscitation 2013; 84: 798–804.

28.

Ameloot

Meex

Genbrugge

, et al. Hemodynamic targets during therapeutic hypothermia after cardiac arrest: a prospective observational study. Resuscitation 2015; 91: 56–62.

29.

Beale

. Too much pressure at the bedside. Crit Care Med 2018; 46: 1698–1700.

30.

Lee

Brady

Mytar

, et al. Cerebral blood flow and cerebrovascular autoregulation in a swine model of pediatric cardiac arrest and hypothermia. Crit Care Med 2011; 39: 2337–2345.

31.

Lilja

Nielsen

Friberg

, et al. Cognitive function in survivors of out-of-hospital cardiac arrest after target temperature management at 33 degrees C versus 36 degrees C. Circulation 2015; 131: 1340–1349.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.43 MB