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


OBJECTIVE
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.


METHODS
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.


RESULTS
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).


CONCLUSIONS
In patients with ROSC after OHCA, EGDHO and TH can be implemented simultaneously.
Gaieski
David F
DF
Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. gaieskid@uphs.upenn.edu
Band
Roger A
RA
Abella
Benjamin S
BS
Neumar
Robert W
RW
Fuchs
Barry D
BD
Kolansky
Daniel M
DM
Merchant
Raina M
RM
Carr
Brendan G
BG
Becker
Lance B
LB
Maguire
Cheryl
C
Klair
Amandeep
A
Hylton
Julie
J
Goyal
Munish
M
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001784:Blood Gas Analysis; D001794:Blood Pressure / Q000502:physiology; D002317:Cardiovascular Agents / Q000627:therapeutic use; D002985:Clinical Protocols; D015331:Cohort Studies; D003128:Coma / Q000209:etiology / Q000503:physiopathology* / Q000628:therapy*; D004636:Emergency Service, Hospital; D005240:Feasibility Studies; D005260:Female; D006323:Heart Arrest / Q000150:complications / Q000401:mortality / Q000628:therapy*; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D012189:Retrospective Studies; D055815:Young Adult
D002317:Cardiovascular Agents; D010100:Oxygen