Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial

Abstract

Aims During the first 6–12 h of intensive care unit (ICU) stay, post-cardiac arrest (CA) patients treated with a mean arterial pressure (MAP) 65 mmHg target experience a drop of the cerebral oxygenation that may cause additional cerebral damage. Therefore, we investigated whether an early goal directed haemodynamic optimization strategy (EGDHO) (MAP 85–100 mmHg, SVO2 65–75%) is safe and could improve cerebral oxygenation, reduce anoxic brain damage, and improve outcome when compared with a MAP 65 mmHg strategy. Methods and results A total of 112 out-of-hospital CA patients were randomly assigned to EGDHO or MAP 65 mmHg strategies during the first 36 h of ICU stay. The primary outcome was the extent of anoxic brain damage as quantified by the percentage of voxels below an apparent diffusion coefficient (ADC) score of 650.10−6 mm2/s on diffusion weighted magnetic resonance imaging (at day 5 ± 2 post-CA). Main secondary outcome was favourable neurological outcome (CPC score 1–2) at 180 days. In patients assigned to EGDHO, MAP (P < 0.001), and cerebral oxygenation during the first 12 h of ICU stay (P = 0.04) were higher. However, the percentage of voxels below an ADC score of 650.10−6 mm2/s did not differ between both groups [16% vs. 12%, odds ratio 1.37, 95% confidence interval (CI) 0.95–0.98; P = 0.09]. Also, the number of patients with favourable neurological outcome at 180 days was similar (40% vs. 38%, odds ratio 0.98, 95% CI 0.41–2.33; P = 0.96). The number of serious adverse events was lower in patients assigned to EGDHO (P = 0.02). Conclusion Targeting a higher MAP in post-CA patients was safe and improved cerebral oxygenation but did not improve the extent of anoxic brain damage or neurological outcome.

Association Between Mean Arterial Pressure and Survival in Patients Admitted to the Intensive Care Unit After Cardiac Arrest With Vasopressor Support: A Retrospective Study

“…The current analysis found the proportion of using vasopressors is higher among non-survivors, which is consistent with the findings of previous observational studies (20,22,25). Although previous studies have shown an association between higher MAP goals achieved with vasopressors and improved outcomes (21,24), a high dosage of vasopressors could cause complications, such as arrhythmia and decreased peripheral perfusion (26). We also found the proportion of using hypothermia is higher among non-survivors, which might not have clinical significance.…”

“…Laurikkala et al prospectively found an association between unfavorable neurological outcome and time spent below a MAP of 70 mmHg in the first 48 h after ROSC, but did not find an association between high vasopressor load and poor outcome(23). In 2019, the Neuro-protect post-CA trial, compared the current standard of care (MAP 65mmHg) with a goal-directed hemodynamic optimization strategy (MAP 85-100mmHg, SVO2 65-75%) found targeting a higher MAP improved brain oxygenation but did not improve the neurological outcome(24).…”

Early Higher Achieved Mean Arterial Pressure Is Not Associated with Clinical Outcomes after Cardiac Arrest: A systematic Review and Meta-analysis

“…Jakkula et al [6] reported that early higher achieved MAP did not affect the serum concentration of neuronspeci c enolase, S100B protein, cardiac troponin, regional frontal cerebral oxygenation, and epileptic activity on the electroencephalography. Ameloot et al [16] did not nd the bene ts of a higher MAP target assessed by magnetic resonance imaging of the cerebrum. Compared with the standard MAP regimen, targeting high MAP in the rst hours of an experimental ECPR model did not result in any hemodynamic improvement nor in a decrease in the amount of infused uid.…”

Diagnose und Therapie des kardiogenen Schocks im akuten Myokardinfarkt

“…Für den septischen Schock konnten bereits randomisierte Studiendaten erhoben werden, die zeigen, dass durch eine Anhebung auf hochnormale Werte (MAP 80-85 mmHg) kein Vorteil zu verzeichnen ist [33]. Bei Patienten nach kardiopulmonaler Reanimation gibt es allerdings Hinweise in einer kleinen randomisierten Studie, dass die zerebrale Oxygenierung verbessert werden könnte [34]. Ob diese Beobachtung allerdings auch Unterschiede im klinischen Überleben mit adäquater zerebraler Funktion bewirken könnte, muss erst durch adäquate, multizentrische Studien geklärt werden.…”