Jeremy S. Pollock

Hyperoxia is associated with increased mortality in patients treated with mild therapeutic hypothermia after sudden cardiac arrest

Objective:To determine whether higher levels of PaO2 are associated with in-hospital mortality and poor neurological status at hospital discharge in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. Design:Retrospective analysis of a prospective cohort. Patients:A total of 170 consecutive patients treated with therapeutic hypothermia in the cardiovascular care unit of an academic tertiary care hospital. Interventions:None. Measurements and Main Results:Of 170 patients, 77 (45.2%) survived to hospital discharge. Survivors had a significantly lower maximum PaO2 (198 mm Hg; interquartile range, 152.5–282) measured in the first 24 hrs following cardiac arrest compared to nonsurvivors (254 mm Hg; interquartile range, 172–363; p = .022). A multivariable analysis including age, time to return of spontaneous circulation, the presence of shock, bystander cardiopulmonary resuscitation, and initial rhythm revealed that higher levels of PaO2 were significantly associated with increased in-hospital mortality (odds ratio 1.439; 95% confidence interval 1.028–2.015; p = .034) and poor neurological status at hospital discharge (odds ratio 1.485; 95% confidence interval 1.032–2.136; p = .033). Conclusions:Higher levels of the maximum measured PaO2 are associated with increased in-hospital mortality and poor neurological status on hospital discharge in patients treated with mild therapeutic hypothermia after sudden cardiac arrest.

Higher achieved mean arterial pressure during therapeutic hypothermia is not associated with neurologically intact survival following cardiac arrest

INTRODUCTION To determine if higher achieved mean arterial blood pressure (MAP) during treatment with therapeutic hypothermia (TH) is associated with neurologically intact survival following cardiac arrest. METHODS Retrospective analysis of a prospectively collected cohort of 188 consecutive patients treated with TH in the cardiovascular intensive care unit of an academic tertiary care hospital. RESULTS Neurologically intact survival was observed in 73/188 (38.8%) patients at hospital discharge and in 48/162 (29.6%) patients at a median follow up interval of 3 months. Patients in shock at the time of admission had lower baseline MAP at the initiation of TH (81 versus 87mmHg; p=0.002), but had similar achieved MAP during TH (80.3 versus 83.7mmHg; p=0.11). Shock on admission was associated with poor survival (18% versus 52%; p<0.001). Vasopressor use among all patients was common (84.6%) and was not associated with increased mortality. A multivariable analysis including age, initial rhythm, time to return of spontaneous circulation, baseline MAP and achieved MAP did not demonstrate a relationship between MAP achieved during TH and poor neurological outcome at hospital discharge (OR 1.28, 95% CI 0.40-4.06; p=0.87) or at outpatient follow up (OR 1.09, 95% CI 0.32-3.75; p=0.976). CONCLUSION We did not observe a relationship between higher achieved MAP during TH and neurologically intact survival. However, shock at the time of admission was clearly associated with poor outcomes in our study population. These data do not support the use of vasopressors to artificially increase MAP in the absence of shock. There is a need for prospective, randomized trials to further define the optimum blood pressure target during treatment with TH.

Delirium in Survivors of Cardiac Arrest Treated With Mild Therapeutic Hypothermia

BACKGROUND Mild therapeutic hypothermia is recommended for comatose patients resuscitated from cardiac arrest. However, the prevalence of delirium and its associated risk factors have not been assessed in survivors of cardiac arrest treated with therapeutic hypothermia. OBJECTIVE To determine the prevalence of and risk factors for delirium among survivors of cardiac arrest who were treated with therapeutic hypothermia. METHODS A retrospective observational study of patients treated with therapeutic hypothermia after cardiac arrest from 2007 through 2014. Baseline demographic data and daily delirium assessments throughout the intensive care unit stay were obtained. The association between duration of delirium and various risk factors was assessed. RESULTS Of 251 patients, 107 (43%) awoke from coma. Among the 107 survivors, all had at least 1 day of delirium during their intensive care unit stay. Median number of days of delirium was 4.0 (interquartile range, 2.0-7.5). Multivariable analysis revealed that age (odds ratio, 1.72; 95% CI, 1.0-2.95; P = .05), time from cardiopulmonary resuscitation to return of spontaneous circulation (odds ratio 1.52; 95% CI, 1.11-2.07; P = .01), and total dose of prewarming propofol (odds ratio, 0.02; 95% CI, 0.00-0.48; P = .02) were associated with duration of delirium. CONCLUSIONS All survivors of cardiac arrest treated with mild therapeutic hypothermia had at least 1 day of delirium. Age and time from initiation of cardiopulmonary resuscitation to return of spontaneous circulation were associated with prolonged delirium, whereas exposure to propofol was protective against delirium. These findings are limited to this unique cohort and may not be generalizable to different populations.

A Collaborative Cardiologist-Intensivist Management Model Improves Cardiac Intensive Care Unit Outcomes

Although the presence of a cardiac intensivist has been shown to reduce cardiac intensive care unit (CICU) mortality [(1)][1], and data from medical and surgical critical care research support multidisciplinary staffing models [(2)][2], the impact of collaboration between cardiologists and

ACUTE ARTERIAL THROMBOSIS DUE TO A HYPERCOAGULABLE STATE MANIFESTING WITH INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION AND CRITICAL LIMB ISCHEMIA

ST-elevation myocardial infarction is usually attributed to acute atherosclerotic plaque rupture. In rare cases, a hypercoagulable state can cause coronary and/or peripheral arterial thrombosis or embolism. Lifelong anticoagulation is necessary in such patients. A 44-year-old woman presented with