2009 Nov – Significance of arterial hypotension after resuscitation from cardiac arrest

Trzeciak, Stephen; Jones, Alan E.; Kilgannon, J Hope; Milcarek, Barry; Hunter, Krystal; Shapiro, Nathan I.; Hollenberg, Steven M.; Dellinger, R Phillip; Parrillo, Joseph E.; Critical Care Medicine. 37(11):2895-2903, November 2009.
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.

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