Factors associated with circulatory death after out-of-hospital cardiac arrest: a population-based cluster analysis

Abstract

Background Out-of-hospital cardiac arrest (OHCA) is a common cause of death. Early circulatory failure is the most common reason for death within the first 48 h. This study in intensive care unit (ICU) patients with OHCA was designed to identify and characterize clusters based on clinical features and to determine the frequency of death from refractory postresuscitation shock (RPRS) in each cluster. Methods We retrospectively identified adults admitted alive to ICUs after OHCA in 2011–2018 and recorded in a prospective registry for the Paris region (France). We identified patient clusters by performing an unsupervised hierarchical cluster analysis (without mode of death among the variables) based on Utstein clinical and laboratory variables. For each cluster, we estimated the hazard ratio (HRs) for RPRS. Results Of the 4445 included patients, 1468 (33%) were discharged alive from the ICU and 2977 (67%) died in the ICU. We identified four clusters: initial shockable rhythm with short low-flow time (cluster 1), initial non-shockable rhythm with usual absence of ST-segment elevation (cluster 2), initial non-shockable rhythm with long no-flow time (cluster 3), and long low-flow time with high epinephrine dose (cluster 4). RPRS was significantly associated with this last cluster (HR, 5.51; 95% confidence interval 4.51–6.74). Conclusions We identified patient clusters based on Utstein criteria, and one cluster was strongly associated with RPRS. This result may help to make decisions about using specific treatments after OHCA.

Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study

“…Paul et al [ 30 ] reported that the majority of subjects with very high Cardiac Arrest Hospital Prognosis (CAHP) scores, which included epinephrine dose and six other variables, were more likely to die of PRS. Binois et al [ 17 ] identified a cluster of patients strongly associated with PRS whose epinephrine dose was notably much higher than others. In this study, we were able to show that this association was not only associated with PRS but also responsible for early mortality from cardiocirculatory causes.…”

“…Patients meeting the criteria for more than one mode of death category were classified according to the primary reason for death. In a previous SDEC work (from 2011 to 2018), we highlighted that the agreement between the two investigators regarding the classification of the mode of death was considered good (kappa coefficient 0.87) [ 17 ]. Secondary endpoints were the survival rate and the time to death according to the mode of death.…”

“…Third, epinephrine decreases cerebral microvascular blood flow and would be responsible for poor neurological outcomes by increasing cerebral ischemia [ 14 ]. These deleterious effects after ROSC are well supported by the fact that the more subjects receive epinephrine during CPR, the more they develop refractory PRS and the lower their survival rate [ 15 – 17 ]. Thus, it seems that the dose of epinephrine used during CPR favors a cardiocirculatory mode of death after ROSC by promoting PRS and re-arrests.…”