P6383Cardiac output during targeted temperature management and renal function after out-of-hospital cardiac arrest

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Grand ◽  
C Hassager ◽  
J Bro-Jeppesen ◽  
M Wanscher ◽  
J Kjaergaard
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Acute Kidney Injury ◽  
Cardiac Index ◽  
Renal Injury ◽  
Kidney Injury ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Research Fund ◽  
Hospital Cardiac Arrest

Abstract Background After resuscitation from out-of-hospital cardiac arrest (OHCA), renal injury and hemodynamic instability are common. Low blood pressure during targeted temperature management (TTM) is associated with acute renal injury (AKI). The aim of this study is to test the hypothesis, that low cardiac output during TTM is associated with acute kidney injury after OHCA. Methods Single-center substudy of 171 patients included in the prospective, randomized TTM-trial. Hemodynamic evaluation was performed with serial measurements by pulmonary artery catheter. Mean arterial pressure ≥65 mmHg and central venous pressure of 10 to 15 mmHg were hemodynamic treatment goals. Acute kidney injury (AKI) was the primary endpoint and was defined according to the KDIGO-criteria. Differences between groups were tested by repeated measurements mixed models. Measurements and main results Of 152 patients with available hemodynamic data, 49 (32%) had AKI and 21 (14%) had AKI with need for renal replacement therapy (RRT) in the first three days. At admission, cardiac index was higher in the AKI-group (mean (confidence interval): 2.6 (2.2–3.0) L/min/m2 versus 2.2 (2.0–2.3) L/min/m2, p=0.003). During 24 hours of targeted temperature management, patients with AKI had increased heart rate (11 beats/min, pgroup<0.0001) and increased lactate (1 mmol/L, pgroup<0.0001) compared to patients without AKI. However, there was no overall difference in cardiac index (pgroup = 0.25) (Figure). In multivariate models, adjusting for potential confounders including targeted temperature, mean arterial pressure (odds ratio: 0.69 (0.50–0.96) per 5 mmHg increase, p=0.03), heart rate (1.04 (1.01–1.08) per beat/min increase, p=0.01) and lactate (1.59 (1.14–2.2) per mmol/L increase, p=0.006) were independently associated with AKI, but cardiac index remained unrelated with AKI. Figure 1 Conclusions Blood pressure, heart rate and lactate, but not cardiac output, during 24 hours of targeted temperature management were associated with renal injury in comatose OHCA-patients. Acknowledgement/Funding The research fund Gangstedfonden and the Research fund of Rigshospitalet has supported this study with unrestricted salary in Dr. Grand's PhD project.

5230Association of cardiac output during targeted temperature management with mortality after out-of-hospital cardiac arrest

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Grand ◽  
J Kjaergaard ◽  
J Bro-Jeppesen ◽  
M Wanscher ◽  
C Hassager
Keyword(s):  
Heart Rate ◽  
Cardiac Arrest ◽  
Multivariate Analysis ◽  
Cardiac Output ◽  
Cardiac Index ◽  
Temperature Management ◽  
Research Fund ◽  
Low Cardiac Output ◽  
Time Points ◽  
Hospital Cardiac Arrest

Abstract Purpose Myocardial dysfunction and low cardiac output are common after out-of-hospital cardiac arrest (OHCA) as part of the post-cardiac arrest syndrome. This study investigates the association of cardiac output during targeted temperature management (TTM) with mortality. We hypothesized that low cardiac output during TTM is associated with mortality. Methods In the TTM-trial, which randomly allocated patients to TTM of 33°C or 36°C for 24 hours, we prospectively and consecutively monitored 171 patients with protocolized measurements from pulmonary artery catheters (PAC). Clinical and hemodynamic variables were registered at pre-specified time points in addition to 30-day survival status. Lactate, heart rate and cardiac index were measured at 3 time-points during TTM and averaged. We defined low cardiac output as a cardiac index during TTM <2.4 l/min/m2 in the TTM36-group and <1.8 l/min/m2 in the TTM33-group, since hypothermia affects cardiac output. We further stratified patients according to serum lactate (above/below 2 mmol/L) and heart rate (above/below median, which was 65 beats/min.). Results Of 152 patients with available hemodynamic measurements, 71 (47%) had low cardiac output during TTM (TTM33: 38 (49%), TTM36: 33 (44%)). Low cardiac output was not associated with mortality in univariate analysis (hazard ratio (HR): 1.47 [0.83–2.59], p=0.19) or multivariate analysis adjusted for potential confounders (HRadjusted: 0.74 [0.38–1.44], p=0.37). Low cardiac output combined with HR>65 was associated with increased mortality (HR: 2.69 [1.51–4.79], p=0.0007) in univariate, but not in multivariate analysis (p=0.22) (Figure). Low cardiac output and HR<65 was associated with decreased mortality in multivariate analysis (HRadjusted: 0.36 [0.14–0.93], p=0.03). Low cardiac output and lactate>2mmol/L was associated with increased mortality (HR: 2.73 [1.49–4.99], p=0.001) in univariate, but not in multivariate analysis (p=0.53), whereas patients with low cardiac output and lactate<2mmol/L had low mortality (HRadjusted: 0.58 [0.27–1.24], p=0.16) compared to the rest of the population (Figure). Figure 1 Conclusion This study found, that a frequent symptom during TTM is low cardiac output, which was not associated with mortality. However, patients with low cardiac output combined with either increased lactate or heart rate seems to be a population at risk. Whether low cardiac output should be corrected by inotropes or mechanical support to reduce mortality remains to be studied in prospective trials, but the efficacy of goal-directed therapy to increase cardiac output during TTM may be modest, especially if lactate and heart rate are normal. Acknowledgement/Funding The research fund Gangstedfonden and the Research fund of Rigshospitalet has supported this study with unrestricted salary in Dr. Grand's PhD project.

scholarly journals Recovery from acute kidney injury is an independent predictor of survival at 30 days only after out-of-hospital cardiac arrest who were treated by targeted temperature management

2021 ◽  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Arrest ◽  
Multivariate Analysis ◽  
Neurological Outcome ◽  
Independent Predictor ◽  
Kidney Injury ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Recovery Group ◽  
Hospital Cardiac Arrest

Background: Development of acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is associated with mortality and poor neurological outcome. However, the effect of recovery from AKI after OHCA is uncertain. This study investigates whether recovery from AKI was associated with the rate of survival and neurological outcome at 30 days after OHCA. Methods: This is a prospective multicentre observational cohort study of adult OHCA patients treated with targeted temperature management (TTM) across five hospitals in South Korea between February 2019 and July 2020. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was the rate of survival at 30 days, and the secondary outcome was the rate of survival with a favourable neurological outcome at 30 days, defined by a score of 3 or less on the modified Rankin scale. Results: Among the 2,018 patients with OHCA, 79 were treated with TTM. After excluding two patients with incomplete data on outcomes, 77 were analysed. AKI developed in 43 (56%) patients. Among them, 22 (51%) recovered from AKI. Although the rate of survival at 30 days for the recovery group was superior to the non-recovery group (82% vs. 24%, P < 0.001), the rate of survival with a favourable neurological outcome at 30 days for the recovery group was not different than that for the non-recovery group (32% vs. 10%, P = 0.132). Recovery from AKI was an independent predictor of survival at 30 days after OHCA in the multivariate analysis (adjusted odds ratio, 22.737; 95% confidence interval, 3.814-135.533; P = 0.001); however, it was not associated with a favourable neurological outcome at 30 days after OHCA in the multivariate analysis. Conclusion: Recovery from AKI was an independent predictor of survival at 30 days only after OHCA who were treated by TTM.

scholarly journals Associations of Intraoperative Radial Arterial Systolic, Diastolic, Mean, and Pulse Pressures with Myocardial and Acute Kidney Injury after Noncardiac Surgery

2020 ◽  
Vol 132 (2) ◽  
pp. 291-306 ◽  
Author(s):  
Sanchit Ahuja ◽  
Edward J. Mascha ◽  
Dongsheng Yang ◽  
Kamal Maheshwari ◽  
Barak Cohen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Acute Kidney Injury ◽  
Pulse Pressure ◽  
Renal Injury ◽  
Myocardial Injury ◽  
Kidney Injury ◽  
Noncardiac Surgery ◽  
Complex Signal ◽  
Discriminative Ability ◽  
Increased Risk

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. Methods The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients’ lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. Results Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P &lt; 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P &lt; 0.001), but not diastolic, after adjusting for confounding. Conclusions Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.

scholarly journals The influence of prolonged temperature management on acute kidney injury after out-of-hospital cardiac arrest: A post hoc analysis of the TTH48 trial

Resuscitation ◽  
2020 ◽  
Vol 151 ◽  
pp. 10-17 ◽  
Author(s):  
Kristian Strand ◽  
Eldar Søreide ◽  
Hans Kirkegaard ◽  
Fabio Silvio Taccone ◽  
Anders Morten Grejs ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Arrest ◽  
Kidney Injury ◽  
Temperature Management ◽  
Post Hoc Analysis ◽  
Post Hoc ◽  
Hospital Cardiac Arrest

Abstract 216: Renal Failure After Cardiac Arrest and the role of Targeted Temperature Management

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Abhishek Bhardwaj ◽  
Steve Balian ◽  
David G Buckler ◽  
Benjamin S Abella
Keyword(s):  
Cardiac Arrest ◽  
Kidney Disease ◽  
Kidney Injury ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Common Complication ◽  
Baseline Serum ◽  
Incidence Of Ckd ◽  
Hospital Cardiac Arrest

Introduction: While Acute Kidney Injury (AKI) is a common complication of cardiac arrest (CA), the incidence of AKI and Chronic Kidney Disease (CKD) following resuscitation are not well studied. Further, the association of Targeted Temperature Management (TTM) with AKI and CKD incidence has not been extensively studied. Aim: We compared the incidence of post-arrest AKI and CKD among patients who received TTM and those who did not receive TTM. Methods: In this retrospective cohort study, we studied adult patients following resuscitation from out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Serum creatinine (Cr) data for post-arrest patients were extracted from the electronic medical record. Baseline serum Cr was defined as the most recent pre-arrest Cr value or the lowest Cr value within 6 hrs of arrest. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, AKI was defined as an increase in Cr by > 0.3 mg/dL within 48 hrs or an increase in serum Cr by 1.5x the baseline value within a one-week period. CKD was defined as a GFR of < 60 mL/min per 1.73 m 2 3 months post-arrest. Results: From 1/2005 to 12/2017, 1099 patients had serial post-arrest creatinine values available. Median age at arrest was 63 (IQR 25), 58% were male, survival to discharge was 20%, with a 17 % favorable CPC score of 1 or 2. Of these, 240 patients had documented TTM status (89 received TTM and 151 did not). Of the patients who received TTM, 31% developed AKI compared to 40 % who did not receive TTM (P=NS). The incidence of CKD was 56% in the TTM group and 45% in the non-TTM group. McNemar’s test for CKD at baseline and at 3 months post-arrest showed a significant increase in the incidence of CKD post arrest (45% vs. 49%, p = 0.031). Conclusions: Post cardiac arrest, AKI and CKD are common complications. The use of TTM was not associated with the incidence of AKI or CKD. Further research is needed to study factors that affect AKI and CKD in CA.

scholarly journals Haemodynamics and vasopressor support during prolonged targeted temperature management for 48 hours after out-of-hospital cardiac arrest: a post hoc substudy of a randomised clinical trial

2020 ◽  
pp. 204887262093430
Author(s):  
Johannes Grand ◽  
Christian Hassager ◽  
Markus B Skrifvars ◽  
Marjaana Tiainen ◽  
Anders M Grejs ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Heart Rate ◽  
Cardiac Arrest ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Randomised Clinical Trial ◽  
Hazard Ratio ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Hospital Cardiac Arrest

Background Comatose patients admitted after out-of-hospital cardiac arrest frequently experience haemodynamic instability and anoxic brain injury. Targeted temperature management is used for neuroprotection; however, targeted temperature management also affects patients’ haemodynamic status. This study assessed the haemodynamic status of out-of-hospital cardiac arrest survivors during prolonged (48 hours) targeted temperature management at 33°C. Methods Analysis of haemodynamic and vasopressor data from 311 patients included in a randomised, clinical trial conducted in 10 European hospitals (the TTH48 trial). Patients were randomly allocated to targeted temperature management at 33°C for 24 (TTM24) or 48 (TTM48) hours. Vasopressor and haemodynamic data were reported hourly for 72 hours after admission. Vasopressor load was calculated as norepinephrine (µg/kg/min) plus dopamine(µg/kg/min/100) plus epinephrine (µg/kg/min). Results After 24 hours, mean arterial pressure (mean±SD) was 74±9 versus 75±9 mmHg ( P=0.19), heart rate was 57±16 and 55±14 beats/min ( P=0.18), vasopressor load was 0.06 (0.03–0.15) versus 0.08 (0.03–0.15) µg/kg/min ( P=0.22) for the TTM24 and TTM48 groups, respectively. From 24 to 48 hours, there was no difference in mean arterial pressure ( Pgroup=0.32) or lactate ( Pgroup=0.20), while heart rate was significantly lower (average difference 5 (95% confidence interval 2–8) beats/min, Pgroup<0.0001) and vasopressor load was significantly higher in the TTM48 group ( Pgroup=0.005). In a univariate Cox regression model, high vasopressor load was associated with mortality in univariate analysis (hazard ratio 1.59 (1.05–2.42) P=0.03), but not in multivariate analysis (hazard ratio 0.77 (0.46–1.29) P=0.33). Conclusions In this study, prolonged targeted temperature management at 33°C for 48 hours was associated with higher vasopressor requirement but no sign of any detrimental haemodynamic effects.

Sign in / Sign up

Export Citation Format

Share Document