Post-cardiac arrest care. Targeted temperature management and coronary care

Sammanfattning: AbstractOut-of-hospital cardiac arrest is a devastating manifestation of coronary artery disease. For patients who are initially resuscitated and are admitted to an intensive care unit, mortality is high. Roughly half of all patients die, primarily due to neurological injury. In recent years, some improvement in outcomes has been seen, perhaps in some part due to interventions performed in hospital.This thesis consists of four papers that examine different aspects of post-cardiac arrest care. Paper I – A retrospective study of 84 patients with both in-hospital and out-of hospital cardiac arrest examines the potential utility of Heparin-binding protein as a prognostic biomarker. HBP, an early marker of circulatory failure in sepsis was generally elevated after cardiac arrest, primarily very early after ROSC. Levels of HBP were associated with critical illness as assessed by the SOFA-score. HBP had a modest ability to predict neurological outcome. Paper II – A post-hoc analysis of the TTM-trial studied the use of early coronary angiography for patients without ST-elevation on their initial ECG. Out of 939 patients included in the TTM-trial, 544 did not have initial ST-elevation. Among these patients 46% received a coronary angiography within 6 hours of arrest, obstructive coronary artery disease was common, as evidenced by 101 patients who received a percutaneous coronary intervention. In an adjusted analysis neither survival nor a good neurological outcome were associated with the use of an early coronary angiography. Results were similar in a propensity score analysis. Paper III – Based on the hypothesis that targeted temperature management is primarily efficacious for patients with severe brain damage, paper III examined the relationship between the effect of targeted temperature management at 33°C and 36°C in relation to no flow-time. There was no significant interaction between no flow-time and temperature. Using adjusted predictions there was no evidence that a target temperature of 33°C was more effective for patients with long no-flow times. Paper IV – There is conflicting evidence regarding if target temperature management to 33°C is associated with an increased risk of infections. Whether infections after cardiac arrest are associated with mortality in also debated. In paper IV, a post-hoc analysis of the TTM-trial, the incidence of infections was not significantly higher among patients treated at 33°C as compared to 36°C. However, there was a trend towards more infections in the 33°C group. In a multivariate analysis, infections