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Association of prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest

      Abstract

      Introduction

      Hypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival.

      Methods

      We utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses by hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) were conducted using adjusted Cox proportional hazards models.

      Results

      17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently associated with STH. Differences in hypotension management were not associated with differences in survival or time to hypotension resolution.

      Conclusion

      Severity and duration of hypotension were significantly associated with worse outcomes in this dataset. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.

      Keywords

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      References

        • Tsao C.W.
        • et al.
        Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association.
        Circulation. 2022; 145: e153-e639
        • Spigner M.F.
        • et al.
        Prehospital Protocols for Post-Return of Spontaneous Circulation Are Highly Variable.
        Prehosp Emerg Care. 2021; 25: 191-195
        • Lin Y.R.
        • et al.
        Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest.
        Resuscitation. 2010; 81: 410-417
        • Bray J.E.
        • et al.
        The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology.
        Resuscitation. 2014; 85: 509-515
        • Chiu Y.K.
        • Lui C.T.
        • Tsui K.L.
        Impact of hypotension after return of spontaneous circulation on survival in patients of out-of-hospital cardiac arrest.
        Am J Emerg Med. 2018; 36: 79-83
        • Lacocque J.
        • Siegel L.
        • Sporer K.A.
        Prehospital, post-ROSC blood pressure and associated neurologic outcome.
        Am J Emerg Med. 2021; 49: 195-199
        • Javaudin F.
        • et al.
        Impact of pre-hospital vital parameters on the neurological outcome of out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry.
        Resuscitation. 2018; 133: 5-11
        • Whelton P.K.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: A report of the American college of cardiology/American heart association task force on clinical practice guidelines.
        Hypertension. 2018; 71: 1269-1324
        • Spaite D.W.
        • et al.
        The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury.
        Ann Emerg Med. 2017; 69: 62-72
        • Spaite D.W.
        • et al.
        Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold.
        JAMA Surg. 2017; 152: 360-368
        • Spaite D.W.
        • et al.
        Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality.
        Ann Emerg Med. 2017; 70: 522-530 e1
        • Gaither J.B.
        • et al.
        Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids).
        Ann Emerg Med. 2021; 77: 139-153
        • Spaite D.W.
        • et al.
        Association of Statewide implementation of the prehospital traumatic brain injury treatment guidelines with patient survival following traumatic brain injury: the excellence in prehospital injury care (EPIC) study.
        JAMA Surg. 2019; 154: e191152
        • Manole M.D.
        • et al.
        Magnetic resonance imaging assessment of regional cerebral blood flow after asphyxial cardiac arrest in immature rats.
        J Cereb Blood Flow Metab. 2009; 29: 197-205
        • Lee J.K.
        • et al.
        Cerebral blood flow and cerebrovascular autoregulation in a swine model of pediatric cardiac arrest and hypothermia.
        Crit Care Med. 2011; 39: 2337-2345
        • Sundgreen C.
        • et al.
        Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest.
        Stroke. 2001; 32: 128-132
        • Nishizawa H.
        • Kudoh I.
        Cerebral autoregulation is impaired in patients resuscitated after cardiac arrest.
        Acta Anaesthesiol Scand. 1996; 40: 1149-1153
        • Pham P.
        • et al.
        Are changes in cerebrovascular autoregulation following cardiac arrest associated with neurological outcome? Results of a pilot study.
        Resuscitation. 2015; 96: 192-198
        • Mullner M.
        • et al.
        Arterial blood pressure after human cardiac arrest and neurological recovery.
        Stroke. 1996; 27: 59-62
        • Kirschen M.P.
        • et al.
        Deviations from PRx-derived optimal blood pressure are associated with mortality after cardiac arrest.
        Resuscitation. 2022;
        • Bottiger B.W.
        • et al.
        The cerebral 'no-reflow' phenomenon after cardiac arrest in rats–influence of low-flow reperfusion.
        Resuscitation. 1997; 34: 79-87
        • Li L.
        • et al.
        Cerebral microcirculatory alterations and the no-reflow phenomenon in vivo after experimental pediatric cardiac arrest.
        J Cereb Blood Flow Metab. 2019; 39: 913-925
        • Ginsberg M.D.
        • Myers R.E.
        The topography of impaired microvascular perfusion in the primate brain following total circulatory arrest.
        Neurology. 1972; 22: 998-1011
        • Safar P.
        • et al.
        Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion.
        Stroke. 1996; 27: 105-113
        • Sterz F.
        • et al.
        Hypertension with or without hemodilution after cardiac arrest in dogs.
        Stroke. 1990; 21: 1178-1184