Lactate, lactate clearance and outcome after cardiac arrest: A post-hoc analysis of the TTM-Trial

BACKGROUND

Admission lactate and lactate clearance are implemented for risk stratification in sepsis and trauma. In out-of-hospital cardiac arrest, results regarding outcome and lactate are conflicting.

METHODS

This is a post-hoc analysis of the Target Temperature Management trial in which 950 unconscious patents after out-of-hospital cardiac arrest were randomized to a temperature intervention of 33°C or 36°C. Serial lactate samples during the first 36 hours were collected. Admission lactate, 12-hour lactate, and the clearance of lactate within 12 hours after admission were analyzed and the association with 30-day mortality assessed.

RESULTS

Samples from 877 patients were analyzed. In univariate logistic regression analysis, the odds ratio for death by day 30 for each mmol/L was 1.12 (1.08-1.16) for admission lactate, P < .01, 1.21 (1.12-1.31) for 12-hour lactate, P < .01, and 1.003 (1.00-1.01) for each percentage point increase in 12-hour lactate clearance, P = .03. Only admission lactate and 12-hour lactate levels remained significant after adjusting for known predictors of outcome. The area under the receiver operating characteristic curve was 0.65 (0.61-0.69), P < .001, 0.61 (0.57-0.65), P < .001, and 0.53 (0.49-0.57), P = .15 for admission lactate, 12-hour lactate, and 12-hour lactate clearance, respectively.

CONCLUSIONS

Admission lactate and 12-hour lactate values were independently associated with 30-day mortality after out-of-hospital cardiac arrest while 12-hour lactate clearance was not. The clinical value of lactate as the sole predictor of outcome after out-of-hospital cardiac arrest is, however, limited.

Impact of initial intervention on long-term neurological recovey after cardiac arrest: data from the Luxembourg "North Pole" cohort

BACKGROUND

Prognosis after cardiac arrest is variable and difficult to predict. Early prognostic markers would facilitate the care of these patients.

AIMS

Therefore, we evaluated the impact of initial interventions after resuscitation on neurological outcome at 6 months.

MATERIAL AND METHODS

We conducted a retrospective analysis of the patient charts from consecutive cardiac arrest patients admitted to our intensive care unit and treated with induced hypothermia.

RESULTS

Over a 3-year period, 90 patients were included in our study. Sixty-four percent of the patients had bystander cardio-pulmonary resuscitation. An automated external defibrillator (AED) was used in 19% of the patients and the mean time to first defibrillation was 11 +/- 8.9 minutes. Patients being resuscitated and defibrillated by bystanders did better than those who had CPR only and far better than those patients in whom no rescue measures where attempted at all (73% vs. 56% vs. 32% for good neurological outcome, respectively, p= 0.03). Witnessed cardiac arrest was more frequent in patients with a good outcome than in those who collapsed without a witness (91% vs 75%, p = 0.03). In 76% of the patients with good outcome, CPR was performed whereas only 52% benefited from these measures in the bad outcome group (p = 0.01). Although the use of an AED was not significantly different between good and bad outcome groups (26% vs. 11%, p = 0.06), time to first defibrillation was significantly lower in patients with good outcome (8.7 +/- 6.3 vs. 13.3 +/- 11.3 minutes, p = 0.05). In the 17 patients in whom an AED was used, 12 (71%) recovered without major sequelae whereas in the 73 cases where no AED was used, only 34 (47%) had a good outcome (p = 0.06). At 6 months follow-up, 46 (51%) survivors had a good outcome (cerebral performance category 1-2), 5 (6%) survived with severe neurological sequelae or stayed in coma and 39 (43%) died.

CONCLUSIONS

Our local data confirm that early interventions have a major impact on survival of cardiac arrest patients. Efforts should concentrate on delivering rapid and high quality CPR as well as early defibrillation by AED's to every patient in cardiac arrest. Besides large scale Basic life support training, the introduction of dispatcher assisted CPR and the implementation and use of public AED's could considerably help to improve outcome in these patients.

Bleeding duodenal varices, an unusual presentation of portal hypertension: 3D MSCT of the feeding branches facilitates temporizing treatment by percutaneous transhepatic embolization

Though duodenal varix ruptures account for only 5% of variceal hemorrhages, they often have a fatal outcome with a mortality as high as 40%. Their detection and treatment, which often prove quite difficult endoscopically, benefit of CT imaging and percutaneous endovascular radiological techniques.

Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest

BACKGROUND

Therapeutic hypothermia (TH) after cardiac arrest protects from neurological sequels and death and is recommended in guidelines. The Hypothermia Registry was founded to the monitor outcome, performance and complications of TH.

METHODS

Data on out-of-hospital cardiac arrest (OHCA) patients admitted to intensive care for TH were registered. Hospital survival and long-term outcome (6-12 months) were documented using the Cerebral Performance Category (CPC) scale, CPC 1-2 representing a good outcome and 3-5 a bad outcome.

RESULTS

From October 2004 to October 2008, 986 TH-treated OHCA patients of all causes were included in the registry. Long-term outcome was reported in 975 patients. The median time from arrest to initiation of TH was 90 min (interquartile range, 60-165 min) and time to achieving the target temperature (< or =34 degrees C) was 260 min (178-400 min). Half of the patients underwent coronary angiography and one-third underwent percutaneous coronary intervention (PCI). Higher age, longer time to return of spontaneous circulation, lower Glasgow Coma Scale at admission, unwitnessed arrest and initial rhythm asystole were all predictors of bad outcome, whereas time to initiation of TH and time to reach the goal temperature had no significant association. Bleeding requiring transfusion occurred in 4% of patients, with a significantly higher risk if angiography/PCI was performed (2.8% vs. 6.2%P=0.02).

CONCLUSIONS

Half of the patients survived, with >90% having a good neurological function at long-term follow-up. Factors related to the timing of TH had no apparent association to outcome. The incidence of adverse events was acceptable but the risk of bleeding was increased if angiography/PCI was performed.

Peripheral vascular surgery: update on the perioperative non-surgical management for high cardiac risk patients

This review of the recent literature regarding perioperative management in peripheral vascular surgery emphasizes some of the important features for the 2003 state-of-the-art on non surgical perioperative care for these high cardiac risk patients. The most adapted preoperative cardiac evaluation for each patient is guided by its individual risk factors and clinical history. Perioperative medication should nowadays consist of pre- and postoperative beta-blockers and acetyl salicylic acid, both reducing cardiac morbidity and mortality. Neuraxial locoregional anaesthesia techniques are reasonable alternatives to general anaesthesia because of their potential advantages, by reducing postoperative inflammatory response and reducing procoagulating activity, and increasing peripheral vascular graft patency, but the individual benefit/risk balance has always to be evaluated for patients submitted to aggressive antithrombotic therapy. During the postoperative course, early detection and treatment of postoperative myocardial ischemia or infarction by ST wave changes and/or cardiac enzyme control has to be considered.