the association between global hemodynamics, cerebral oxygenation and survival in post-cardiac...
TRANSCRIPT
The association between global hemodynamics, cerebral oxygenation and survival in post-cardiac
arrest patients
K. Ameloot, I. Meex, C. Genbrugge, F. Jans, W. Mullens, M. Dupont, C. DeDeyne, J. Dens
The Clinical Problem
, 42 yrsOOHCA10’ bystander CPRVF, DC shock -> ROSCInferior STEMI (R/PPCI)
TH by Coolgard
The Clinical Problem
- No vaso-active drugs
- CO2 41mmHg
The Clinical Problem
‘PCAS is a sepsis-like syndrome’
At least 2 major differences with sepsis:1. Rightward shift autoregulation2. Cardiac patient = afterload dependent
The optimal MAP should maintain cerebral perfusion without exposing the damaged myocardium to excessive afterload
Aims
SctO2
MAP
SVO2
Guidelines SctO2 Mortality
> 65 mmHg
> 70 %
?
??
??
Prospective observational trialStudy Patients• 82 PCA survivors between
3/2011-2/2014– NIRS (n=82)– Arterial line (n=82)– Swann-Ganz (n=63)
• Exclusion criteria:– Traumatic cause– Death < 24 hrs– Early withdrawal therapy
Treatment Protocol• General management
– MAP 65mmHg– Saturation > 94%– Normocapnia
• Therapeutic hypothermia– Cooled IV NaCl 0.9 %– 24hrs 33°C– Rewarming 0.3°C / hour
40 45 50 55 60 65 70 75 80 85 9058
60
62
64
66
68
70
72
74
f(x) = 0.228178766258693 x + 50.6249100568038R² = 0.859745655825473
SVO2 (%)
Cere
bral
Sat
urati
on (%
)
n = 1 pair/2 sec x 24 hrs (=hypothermia) = 1 625 141
40 50 60 70 80 90 100 110 120 130 14060
62
64
66
68
70
72
MAP (mmHg)
Cere
bral
Sat
urati
on (%
)MAP dependent MAP independent
y=0.99x+57.99 y=0.00x+67
87 mmHg
67%
Excessive afterloadMaintain SctO2
n=1 625 141
SVO2 72%
SctO2 67%
MAP 87mmHg
Ventriculo-arterial-cerebral coupling
SVO2 67-72%CPC1-3 180 days
OR 8.2495%CI [2.08; 32.68]
P=0.001
Nl
Low
High
OR 95% CI p-value
Bystander CPR<10min yes/no 19.90 [ 1.78 ; 222.11 ] 0.02
Initial rhythm shockable yes/no 1.85 [ 0.52 ; 6.64 ] 0.34
SVO2 [67,72] % yes/no 8.79 [ 1.69 ; 18.36 ] 0.01
Multivariate Model (SVO2)
MAP 76-86mmHgCPC1-3 180 days
OR 2.6495%CI [1.01;6.88]
P=0.04
OR 95% CI p-value
Bystander CPR<10min yes/no 13.41 [ 2.35 ; 76.48 ] 0.003
Initial rhythm shockable yes/no 3.26 [ 1.11 ; 9.52 ] 0.03
MAP[76,86] mmHg yes/no 3.88 [ 1.22 ; 12.33 ] 0.02
Multivariate Model (MAP)
SVO2<67%MAP<76mmHg
Poor Outcome
Patient Characteristics
Causality Target for treatment?
Association Marker of prognosis?
All
Per SVO2 Low Target High p-value ≤ 66% [67,72]% ≥ 73%Number patients 82 27/63 (43%) 18/63 (29%) 18/63 (29%) DemographicsAge (years) 63±13 66±14 60±10 60±16 0.23Male (%) 70±46 59±50 83±38 72±46 0.22Resuscitation parametersOut of Hospital (%) 85±36 93±27 89±33 84±37 0.65Bystander CPR<10 min (%) 82±39 80±40 89±32 62±50 0.14Initial Rhythm Shockable (%) 66±48 50±51 89±32 66±49 0.02Cardiac Cause 90±30 93±27 94±24 83±38 0.46Surface Cooling (%) 52±50 59±50 44±51 44±51 0.51Hemodynamic parametersHeartrate (BPM) 68±16 71±17 66±13 75±13 0.20Echocardiographic LVEF (%) 42±17 34±18 45±17 45±16 0.05MAP (mmHg) 76±8 74±8 75±6 79±9 0.11CVP (mmHg) 17±13 16±7 18±18 15±9 0.73mPAP (mmHg) 26±5 26±6 25±4 25±6 0.78dPAP (mmHg) 19±5 20±5 19±3 18±5 0.35SVO2 (%) 67±9 59±7 70±2 78±3 <0.0001TDCCO (l/min) 3.88±1.26 3.24±1.23 3.97±0.75 4.79±1.19 <0.0001Cerebral Saturation (%) 65±4 64±4 65±5 68±4 0.01
High SVO2 / High Mortality
1. Causality Hypothesis• Hyperdynamic circulation
cerebral hypersaturation • Target for treatment?2. Reduced oxygen consumption• Functional brain death
21
All
Per SVO2 Low Target High p-value ≤ 66% [67,72]% ≥ 73%Number patients 82 27/63 (43%) 18/63 (29%) 18/63 (29%) DemographicsAge (years) 63±13 66±14 60±10 60±16 0.23Male (%) 70±46 59±50 83±38 72±46 0.22Resuscitation parametersOut of Hospital (%) 85±36 93±27 89±33 84±37 0.65Bystander CPR<10 min (%) 82±39 80±40 89±32 62±50 0.14Initial Rhythm Shockable (%) 66±48 50±51 89±32 66±49 0.02Cardiac Cause 90±30 93±27 94±24 83±38 0.46Surface Cooling (%) 52±50 59±50 44±51 44±51 0.51Hemodynamic parametersHeartrate (BPM) 68±16 71±17 66±13 75±13 0.20Echocardiographic LVEF (%) 42±17 34±18 45±17 45±16 0.05MAP (mmHg) 76±8 74±8 75±6 79±9 0.11CVP (mmHg) 17±13 16±7 18±18 15±9 0.73mPAP (mmHg) 26±5 26±6 25±4 25±6 0.78dPAP (mmHg) 19±5 20±5 19±3 18±5 0.35SVO2 (%) 67±9 59±7 70±2 78±3 <0.0001TDCCO (l/min) 3.88±1.26 3.24±1.23 3.97±0.75 4.79±1.19 <0.0001Cerebral Saturation (%) 65±4 64±4 65±5 68±4 0.01
2
1
The Clinical Problem
Summary
SctO2
MAP
SVO2
Guidelines SctO2 Mortality
> 65 mmHg
> 70 %
67 %
87 mmHg
72 %
76-86 mmHg
67-72%
Back-up slides
Hemoglobin and outcomeHb (g/dl)
OR LLC ULC P-value
16 0.70 0.17 2.81 0.61
15 1.89 0.62 5.72 0.26
14 1.55 0.60 4.03 0.36
13 1.78 0.74 4.29 0.20
12 2.88 1.02 8.16 0.04
11 1.52 0.32 7.28 0.60
10 1.11 0.15 8.27 0.92
Hemoglobin and Outcome
The suggested optimal Hemoglobin seems to be 12 g/dl…
… Odds ratio driven by patients below target SVO2
OR LLC ULC P-value
All 2.88 1.02 8.16 0.04
SVO2 < 70% 6.25 1.32 29.43 0.01
SVO2 ≥ 70% 1.00 0.06 17.90 0.33
n = 1 pair/2 sec x 24 hrs (=hypothermia) = 1 625 141