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Significance of arterial hypotension after resuscitation from cardiac arrest*

Trzeciak, Stephen MD, MPH; Jones, Alan E. MD; Kilgannon, J Hope MD; Milcarek, Barry PhD; Hunter, Krystal MBA; Shapiro, Nathan I. MD, MPH; Hollenberg, Steven M. MD; Dellinger, R Phillip MD; Parrillo, Joseph E. MD

doi: 10.1097/CCM.0b013e3181b01d8c
Continuing Medical Education Article
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CME

Objective: Expert guidelines advocate hemodynamic optimization after return of spontaneous circulation (ROSC) from cardiac arrest despite a lack of empirical data on prevalence of post-ROSC hemodynamic abnormalities and their relationship with outcome. Our objective was to determine whether post-ROSC arterial hypotension predicts outcome among postcardiac arrest patients who survive to intensive care unit admission.

Design: Cohort study utilizing the Project IMPACT database (intensive care unit admissions from 120 U.S. hospitals) from 2001–2005.

Setting: One hundred twenty intensive care units.

Patients: Inclusion criteria were: 1) age ≥18 yrs; 2) nontrauma; and 3) received cardiopulmonary resuscitation before intensive care unit arrival.

Interventions: None.

Measurements and Main Results: Subjects were divided into two groups: 1) Hypotension Present—one or more documented systolic blood pressure <90 mm Hg within 1 hr of intensive care unit arrival; or 2) Hypotension Absent—all systolic blood pressure ≥90 mm Hg. The primary outcome was in-hospital mortality. The secondary outcome was functional status at hospital discharge among survivors. A total of 8736 subjects met the inclusion criteria. Overall mortality was 50%. Post-ROSC hypotension was present in 47% and was associated with significantly higher rates of mortality (65% vs. 37%) and diminished discharge functional status among survivors (49% vs. 38%), p < .001 for both. On multivariable analysis, post-ROSC hypotension had an odds ratio for death of 2.7 (95% confidence interval, 2.5–3.0).

Conclusions: Half of postcardiac arrest patients who survive to intensive care unit admission die in the hospital. Post-ROSC hypotension is common, is a predictor of in-hospital death, and is associated with diminished functional status among survivors. These associations indicate that arterial hypotension after ROSC may represent a potentially treatable target to improve outcomes from cardiac arrest.

Assistant Professor (ST), Division of Critical Care Medicine and Emergency Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, Camden, NJ; Assistant Research Director (AEJ), Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC; Assistant Professor of Emergency Medicine (JHK), UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, Camden, NJ; Biostatistician (BM), Cooper University Hospital, Camden, NJ; Statistician II (KH), Cooper University Hospital, Camden, NJ; Research Director (NIS), Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Professor of Medicine (SMH), UMDNJ-Robert Wood Johnson Medical School, Camden, NJ; Director (SMH), Coronary Care, Cooper University Hospital, Camden, NJ; Professor of Medicine (RPD, JEP), UMDNJ-Robert Wood Johnson Medical School, Camden, NJ; Head (RPD), Division of Critical Care Medicine, Cooper University Hospital, Camden, NJ; Chief (JEP), Department of Medicine, Cooper University Hospital, Camden, NJ; Edward D. Viner Chair (JEP), Department of Medicine, Cooper University Hospital, Camden, NJ; and Director (JEP), Cooper Heart Institute, Cooper University Hospital, Camden, NJ.

Dr. Trzeciak’s effort on this project was supported, in part, by Grant K23GM83211 from the National Institutes of Health/National Institute of General Medical Sciences. Dr. Jones’s effort on this project was supported, in part, by Grant K23GM76652 from the National Institutes of Health/National Institute of General Medical Sciences. Dr. Kilgannon’s effort on this project was supported, in part, by a grant from the Emergency Medicine Foundation.

Dr. Trzeciak has previously received research support from Novo Nordisk, Eli Lilly, and Biosite, but he receives no personal remuneration from any commercial interest. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: trzeciak-stephen@cooperhealth.edu

© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins