Introduction:
Much emphasis is placed on who survives after cardiac arrest and how to optimize “good” outcomes. Despite this stress on aggressive post-arrest care and early temperature management, many people still die after admission to the hospital, often with care being withdrawn. The purpose of this study was to assess how and when patients die after undergoing in-hospital post-arrest therapeutic hypothermia (TH).
Methods:
This was a retrospective chart review of adult patients suffering non-traumatic cardiac arrest who had post-arrest care, including TH, initiated between January 2010 and June 2013 in a large, community academic center. All patients followed the same treatment protocol, with TH induced as soon as possible after arrest, regardless of initial rhythm or arrest location. Demographics, Utstein characteristics, and post-arrest variables, including time to withdrawal of care were collected until death or hospital discharge as part of an on-going quality improvement database. Descriptive statistics and associations are presented.
Results:
During the study period, 139 patients were included and 92 (66.2%) died prior to discharge (mean age 61.9 (SD 16.31) years, 88 (63.3%) male). Few (12, 13.0%) of these had early termination of the TH protocol or died (8, 10.0%) while intubated. Overall, 72 (78.3%) patients had care withdrawn. The median time from return of spontaneous circulation (ROSC) to withdrawal of care was 96.6 hours (IQR 66.2, 164.1) and 18 (27.3%) patients had care withdrawn <72 hours from ROSC. All patients were referred to the Gift of Life service but only 9 (12.5%) contributed to organ donation. A minority of patients (20, 27.8%) received a formal palliative care consult. Factors associated with withdrawal of care included family wishes, older age, initial non-shockable arrest rhythm, and longer time from arrest to ROSC.
Conclusion:
More than 75% of this cohort had care withdrawn. Although the majority had care withdrawn more than 72 hours after ROSC, early withdrawal of care was not uncommon. Further study of this group of patients is needed to understand the relationships between pre-arrest predictors of poor prognosis, pre-existing co-morbidities, patient clinical status, and family wishes on the early withdraw of care.
Higher achieved mean arterial pressure during therapeutic hypothermia is not associated with neurologically intact survival following cardiac arrest
