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