title: Hemodynamics and vasopressor support in therapeutic hypothermia after cardiac arrest: prognostic implications.
abstract: OBJECTIVE
  Inducing therapeutic hypothermia (TH) in Out-of-Hospital Cardiac Arrest (OHCA) can be challenging due to its impact on central hemodynamics and vasopressors are frequently used to maintain adequate organ perfusion. The aim of this study was to assess the association between level of vasopressor support and mortality.
  
  
  METHODS
  In a 6-year period, 310 comatose OHCA patients treated with TH were included. Temperature, hemodynamic parameters and level of vasopressors were registered from admission to 24h after rewarming. Level of vasopressor support was assessed by the cardiovascular sub-score of Sequential Organ Failure Assessment (SOFA). The population was stratified by use of dopamine as first line intervention (D-group) or use of dopamine+norepinephrine/epinephrine (DA-group). Primary endpoint was 30-day mortality and secondary endpoint was in-hospital cause of death.
  
  
  RESULTS
  Patients in the DA-group carried a 49% all-cause 30-day mortality rate compared to 23% in the D-group, plog-rank<0.0001, corresponding to an adjusted hazard ratio (HR) of 2.0 (95% CI: 1.3-3.0), p=0.001). The DA-group had an increased 30-day mortality due to neurological injury (HR=1.7 (95% CI: 1.1-2.7), p=0.02). Cause of death was anoxic brain injury in 78%, cardiovascular failure in 18% and multi-organ failure in 4%. The hemodynamic changes of TH reversed at normothermia, although the requirement for vasopressor support (cardiovascular SOFA≥3) persisted in 80% of patients.
  
  
  CONCLUSIONS
  In survivors after OHCA treated with TH the induced hemodynamic changes reversed after normothermia, while the need for vasopressor support persisted. Patients requiring addition of norepinephrine/epinephrine on top of dopamine had an increased 30-day all-cause mortality, as well as death from neurological injury.
authors.affiliation: Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. Electronic address: jbj@dadlnet.dk.
authors.forename: John
authors.initials: J
authors.lastname: Bro-Jeppesen
authors.affiliation: Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
authors.forename: Jesper
authors.initials: J
authors.lastname: Kjaergaard
authors.affiliation: Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
authors.forename: Helle
authors.initials: H
authors.lastname: Søholm
authors.affiliation: Department of Cardiothoracic Anaesthesia, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
authors.forename: Michael
authors.initials: M
authors.lastname: Wanscher
authors.affiliation: Emergency Medical Services, The Capital Region of Denmark, Copenhagen, Denmark.
authors.forename: Freddy K
authors.initials: FK
authors.lastname: Lippert
authors.affiliation: Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
authors.forename: Jacob E
authors.initials: JE
authors.lastname: Møller
authors.affiliation: Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Køber
authors.affiliation: Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Hassager
mesh_terms: D002423:Cause of Death; D003128:Coma; D015897:Comorbidity; D004298:Dopamine / Q000627:therapeutic use; D004837:Epinephrine / Q000627:therapeutic use; D005260:Female; D006439:Hemodynamics / Q000187:drug effects; D017052:Hospital Mortality; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000627:therapeutic use; D058687:Out-of-Hospital Cardiac Arrest / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D011379:Prognosis; D015996:Survival Rate; D013566:Sympathomimetics / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D013566:Sympathomimetics; D004298:Dopamine; D009638:Norepinephrine; D004837:Epinephrine
keywords: Cardiac arrest; Hemodynamics; Hypothermia; Inotropic agents; Mortality