Skip Ribbon Commands
Skip to main content
SharePoint

PublicComment

 Feedback

If you have any comments or questions on this page, please email us at:
 

Postresuscitation Hemodynamic Support

Question Type:
Intervention
Full Question:
Among adults with ROSC after cardiac arrest in any setting  (P), does  titration of therapy to achieve a specific hemodynamic goal (eg, MAP greater than 65 mm Hg) (I), compared with  no hemodynamic goal  (C), change  (O)?
Consensus on Science:
There are no RCTs addressing hemodynamic goals after resuscitation. Titration of Therapy to Achieve a Specific Hemodynamic Goal (eg, MAP of More Than 65 mm Hg) Compared With No Hemodynamic Goal For the critical outcome of survival with favorable neurologic/functional outcome, very-low-quality evidence (downgraded for risk of bias and publication bias) from 1 multicenter retrospective nonintervention study including 8736 subjects showed post–cardiac arrest SBP less than 90 mm Hg was associated with higher mortality (65% versus 37%) and diminished discharge functional status in survivors (49% versus 38%).(Trzeciak 2009, 2895) For the critical outcome of survival, very-low-quality evidence (downgraded for risks of bias and publication bias) from 2 retrospective single-center studies including 2282 patients showed reduced survival for patients with post-ROSC SBP less than 90 mm Hg(Bray 2014, 509) and less than 100 mm Hg.(Kilgannon 2008, 499) Bundle of Therapies With a Specific Blood Pressure Target Compared With No Bundle For the critical outcome of survival with favorable neurologic/functional outcome, we found very-low-quality evidence (downgraded for risks of bias and publication bias) from 7 studies that included 813 subjects. One pre-/poststudy of early goal-directed therapy of 36 patients with a MAP target greater than 80 mm Hg showed no difference in mortality or neurologic outcome at hospital discharge.(Gaieski 2009, 418) One prospective observational study of 118 patients using historic controls showed that aiming for MAP greater than 65 mm Hg increased survival to hospital discharge with a favorable neurologic outcome at 1 year in 34 of 61 (56%) versus 15 of 58 (26%) in the control period (OR, 3.61; CI, 1.66–7.84; P=0.001).(Sunde 2007, 29-39) One cohort study of 148 patients showed no difference in neurologic outcome at hospital discharge when a MAP less than 75 mm Hg was a threshold for intervention.(Laurent 2002, 2110-2116) One retrospective study of 136 patients identified groups with MAP greater than 100 mm Hg or less than 100 mm Hg after ROSC. Good neurologic recovery was independently and directly related to MAP measured during 2 hours after ROSC (r2=0.26).(Mullner 1996, 59) One before-and-after observational study of a care bundle, including 55 subjects aiming for a MAP greater than 65 mm Hg within 6 hours, showed no change of in-hospital mortality (55.2% [bundle] versus 69.2% [prebundle]) or CPC 1 or 2 (31% versus 12%).(Walters 2011, 360-366) In 1 prospective single-center observational study of 151 patients receiving a bundle of therapies where 44 (29%) experienced good neurologic outcome, a time-weighted average MAP threshold greater than 70 mm Hg had the strongest association with good neurologic outcome (OR, 4.11; 95% CI, 1.34–12.66; P=0.014).(Kilgannon 2014, 2083-2091) One retrospective study of bundle therapy targeting a MAP greater than 80 mm Hg in 168 patients showed survivors had higher MAPs at 1 hour (96 versus 84 mm Hg), 6 hours (96 versus 90 mm Hg; P=0.014), and 24 hours (86 versus 78 mm Hg) when compared with nonsurvivors. Increased requirement for vasoactive drugs was associated with mortality at all time points. Among those requiring vasoactive drugs, survivors had higher MAPs than nonsurvivors at 1 hour (97 versus 82 mm Hg) and 6 hours (94 versus 87 mm Hg).(Beylin 2013, 1981) For the critical outcome of survival, we found very-low-quality evidence (downgraded for risks of bias and publication bias) from 2 studies including 91 patients that assessed the impact of postresuscitation goal-directed/bundles of care (including blood pressure targets) on survival. One pre-/poststudy of early goal-directed therapy of 36 patients including a MAP target greater than 80 mm Hg showed no difference in mortality at hospital discharge.(Gaieski 2009, 418) One pre-/postobservational study of a care bundle including 55 patients aiming for a MAP greater than 65 mm Hg within 6 hours resulted in an in-hospital mortality of 55.2% (bundle) versus 69.2% (prebundle) (P=0.29; RR, 0.80; 95% CI, 0.53–1.21).(Walters 2011, 360)
Treatment Recommendation:
We suggest hemodynamic goals (eg, MAP, SBP) be considered during postresuscitation care and as part of any bundle of postresuscitation interventions (weak recommendation, low-quality evidence). There is insufficient evidence to recommend specific hemodynamic goals; such goals should be considered on an individual patient basis and are likely to be influenced by post–cardiac arrest status and pre-existing comorbidities (weak recommendation, low-quality evidence). Values, Preferences, and Task Force Insights In making these recommendations, we place a higher value on the recognition that while hemodynamic goals are likely important to optimize outcome, specific targets remain unknown and likely vary depending on individual physiology and comorbid status.
CoSTR Attachments:
should-a-blood-pressure-target-achieved-vs-blood-pressure-target-not-achieved-be-used-for-adults-wi.doc    
should-a-bundle-of-goal-directed-therapies-including-achieving-bp-goal-vs-no-bundlenot-achieving-b2.doc    

 Contact Us

 
If you have any comments or questions on this page, please email us at: