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Grand J, Møller JE, Hassager C, Schmidt H, Mølstrøm S, Boesgaard S, Meyer MAS, Josiassen J, Højgaard HF, Frydland M, Dahl JS, Obling LER, Bak M, Lind Jørgensen V, Thomsen JH, Wiberg S, Madsen SA, Nyholm B, Kjaergaard J. Impact of blood pressure targets on central hemodynamics during intensive care after out-of-hospital cardiac arrest. Resuscitation 2024; 194:110094. [PMID: 38103857 DOI: 10.1016/j.resuscitation.2023.110094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES The aim was to investigate the advanced hemodynamic effects of the two MAP-targets during intensive care on systemic hemodynamics in comatose patients after cardiac arrest. DESIGN Secondary analysis of a randomized controlled trial. SETTING Primary vasopressor used was per protocol norepinephrine. Hemodynamic monitoring was done with pulmonary artery catheters (PAC) and measurements were made on predefined time points. The primary endpoint of this substudy was the difference in cardiac index within 48 h from a repeated measurements-mixed model. Secondary endpoints included systemic vascular resistance index (SVRI), heart rate, and stroke volume index. PATIENTS Comatose survivors after out-of-hospital cardiac arrest. INTERVENTIONS The "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial was a randomized, controlled, double-blinded, multicenter-study comparing targeted mean arterial pressure (MAP) of 63 mmHg (MAP63) vs 77 mmHg (MAP77). MEASUREMENTS AND MAIN RESULTS Among 789 randomized patients, 730 (93%) patients were included in the hemodynamic substudy. From PAC-insertion (median 1 hours after ICU-admission) and the next 48 hours, the MAP77-group received significantly higher doses of norepinephrine (mean difference 0.09 µg/kg/min, 95% confidence interval (CI) 0.07-0.11, pgroup < 0.0001). Cardiac index was significantly increased (0.20 L/min/m2 (CI 0.12-0.28), pgroup < 0.0001) as was SVRI with an overall difference of (43 dynes m2/s/cm5 (CI 7-79); pgroup = 0.02). Heart rate was increased in the MAP77-group (4 beats/minute; CI 2-6, pgroup < 0.003), but stroke volume index was not (pgroup = 0.10). CONCLUSIONS Targeted MAP at 77 mmHg compared to 63 mmHg resulted in a higher dose of norepinephrine, increased cardiac index and SVRI. Heart rate was also increased, but stroke volume index was not affected by a higher blood pressure target.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital, Amager-Hvidovre, Copenhagen, Denmark.
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark; Clinical Institute University of Southern Denmark, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Simon Mølstrøm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Søren Boesgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Martin Frydland
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark; Clinical Institute University of Southern Denmark, Denmark
| | | | - Mikkel Bak
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Hartvig Thomsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Grand J, Hassager C, Schmidt H, Mølstrøm S, Nyholm B, Høigaard HF, Dahl JS, Meyer M, Beske RP, Obling L, Kjaergaard J, Møller JE. Serial assessments of cardiac output and mixed venous oxygen saturation in comatose patients after out-of-hospital cardiac arrest. Crit Care 2023; 27:410. [PMID: 37891623 PMCID: PMC10612339 DOI: 10.1186/s13054-023-04704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023] Open
Abstract
AIM To assess the association with outcomes of cardiac index (CI) and mixed venous oxygen saturation (SvO2) in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In the cohort study of 789 patients included in the "BOX"-trial, 565 (77%) patients were included in this hemodynamic substudy (age 62 ± 13 years, male sex 81%). Pulmonary artery catheters were inserted shortly after ICU admission. CI and SvO2 were measured as soon as possible in the ICU and until awakening or death. The endpoints were all-cause mortality at 1 year and renal failure defined as need for renal replacement therapy. RESULTS First measured CI was median 1.7 (1.4-2.1) l/min/m2, and first measured SvO2 was median 67 (61-73) %. CI < median with SvO2 > median was present in 222 (39%), and low SvO2 with CI < median was present in 59 (11%). Spline analysis indicated that SvO2 value < 55% was associated with poor outcome. Low CI at admission was not significantly associated with mortality in multivariable analysis (p = 0.14). SvO2 was significantly inversely associated with mortality (hazard ratioadjusted: 0.91 (0.84-0.98) per 5% increase in SvO2, p = 0.01). SvO2 was significantly inversely associated with renal failure after adjusting for confounders (ORadjusted: 0.73 [0.62-0.86] per 5% increase in SvO2, p = 0.001). The combination of lower CI and lower SvO2 was associated with higher risk of mortality (hazard ratioadjusted: 1.54 (1.06-2.23) and renal failure (ORadjusted: 5.87 [2.34-14.73]. CONCLUSION First measured SvO2 after resuscitation from OHCA was inversely associated with mortality and renal failure. If SvO2 and CI were below median, the risk of poor outcomes increased significantly. REGISTRATION The BOX-trial is registered at clinicaltrials.gov (NCT03141099, date 2017-30-04, retrospectively registered).
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Affiliation(s)
- Johannes Grand
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Cardiology, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark.
| | - Christian Hassager
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | | | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
| | - Martin Meyer
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rasmus P Beske
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laust Obling
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
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