Electronic supplementary data.
Intensive care unit mortality after cardiac arrest: the relative
contribution of shock and brain injury in a large cohort.
Virginie Lemiale, MD(1,5) ; Florence Dumas, MD(2,6); Nicolas Mongardon, MD(1,5) ; Olivier
Giovanetti, MD(6) ; Julien Charpentier,MD(1,5); Jean-Daniel Chiche, MD(1,5) ; Pierre Carli,
MD(4,5) ; Jean-Paul Mira, MD(1,5) ; Jerry Nolan, FRCA, FRCP(3) ; Alain Cariou, MD(1,5,6)
1
Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Universitaire Cochin
Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg SaintJacques, 75014 Paris, France
2 Emergency
Department, Cochin Hospital, Groupe Hospitalier Universitaire Cochin Broca
Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques,
75014 Paris, France
3
Intensive Care Unit, Royal United Hospital, Combe Park, BA1 3NG, Bath, United-
Kingdom
4
SAMU 75, Necker Hospital, Assistance Publique des Hôpitaux de Paris, 149, rue de
Sèvres,- 75015Paris, France
5 Université
Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l’Ecole
de Médecine, 75006 Paris, France
6
INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges
Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France
Management of OHCA patients during ICU stay
Briefly, since 2000, immediately after OHCA and when no obviously other etiology
than cardiac origin was retained, all patient had coronary angiogram with PCI if needed.
When coronary angiography was not conclusive, brain and angio-thoracic CT scan were
performed. When indicated, hypothermia treatment was initiated immediately at ICU
admission using external cooling by forced cold air during the first 24 hours to obtain a
target temperature between 32 and 34°C as recommended by international guidelines [1,2].
During the first 48 hours of ICU stay, treatments were adapted to maintain homeostasis with
glucose control, normocapnia maintenance, inspired fraction of O2 (FiO2) for arterial
saturation of 94-98%, mean arterial pressure target as 65-70mmHg, and hemoglobin level
over 7g/dL [3].
Neurological assessment
Neurological outcome as daily assessed by ICU physicians until death or ICU discharge
(fig 1 of ESM). Particularly, in difficult situations (i.e., patients with N20 potentials and/or
cranial reflexes preserved), decisions to withhold or withdraw life-support therapies were
systematically delayed in order to search for a confounding factor (sepsis, remaining
sedative drug effect, intercurrent disease process, other neurological disease). At this step, a
decision was proposed after discussion between all team members (intensivists, nurses,
neurologist, therapist), taking into account all prognostic variables. This decision could be
either to withhold or withdraw life-support therapies, or to wait for an additional follow-up
period.
According to guidelines and recent studies [4-7], life-sustaining treatments were
withdrawn in case of absence of pupillary responses, absence of corneal reflexes, absent or
extensor motor responses, and bilateral absence of the N20 component of the
somatosensory evoked potentials with median nerve stimulation recorded at minimum on
day 3 after CA. In patients who were treated by therapeutic hypothermia, this neurological
assessment was systematically delayed in order to wait for sedative drugs’ elimination. Lifesustaining therapies withdrawal was always decided after a collegial decision. All deaths
associated with such end-of-life decisions occurred during the ICU stay. If spontaneous
ventilation was present, the patient was extubated and kept in the ICU until death. No
patient was discharged from the ICU after terminal extubation. If there was no spontaneous
ventilation, vasoactive drugs were stopped, the inspired oxygen concentration was reduced
to 21%, and the end-expiratory pressure set to zero. Brain death was diagnosed according to
the current French legal framework [8], with the combination of clinical features (absence of
motor response, spontaneous ventilation and brainstem reflex) and the absence of
electroencephalographic activity or cerebral perfusion during cerebral CT scan.
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Décret no 96-1041 du 2 décembre 1996 (1996) relatif au constat de la mort préalable au
prélèvement d'organes, de tissus et de cellules à des fins thérapeutiques ou scientifiques et
modifiant le code de la santé publique (deuxième partie : Décrets en Conseil d'Etat). JORF
282 : 17615
Figure 1 ESM : decision algorithm for post-CA patients.
EEG: electro-encephalogram; ICU: Intensive Care Unit.
Figure 2 ESM : Mode of death according to the study period
Table 1 ESM: Baseline characteristics according to the mode of death
Total
n=1152
ICU survival
n=384
57 (16)
294 (76)
203 (54)
ICU death related
to post cardiac
arrest shock
n=269
61 (16)
191 (71)
103 (39)
ICU death related
to neurological
injury
n=499
59 (16)
357 (71)
158 (32)
Age, yrs (SD)
Male sex, n(%)
Bystander CPR, n(%)
Cardiac arrest location, n(%)
Home
Public area
59 (16)
842 (73)
464 (41)
771 (67)
378 (33)
212 (55)
172 (45)
192 (72)
74 (28)
367 (74)
132 (26)
Shockable rhythm, n(%)
654 (57)
294 (77)
124 (46)
236 (47)
Time from collapse to ROSC
<12 min
12-20 min
20-31 min
> 31min
252 (25)
205 (20)
292 (29)
257 (26)
150 (44)
88 (26)
63 (18)
41 (12)
32 (15)
32 (15)
66 (30)
88 (40)
70 (16)
85 (19)
163 (37)
128 (29)
Admission lactate value
<2.5 mmol/l
2.5-5 mmol/l
5-9.3 mmol/l
>9.3 mmol/l
247 (26)
240 (25)
238 (25)
242 (25)
161 (49)
88 (26)
56 (17)
21 (6)
13 (6)
25 (12)
40 (19)
132 (63)
73 (17)
127 (29)
142 (33)
89 (21)
294 (26)
265 (24)
281 (25)
276 (25)
165 (43)
94 (25)
71 (19)
53 (14)
212 (55)
272 (71)
-
22 (9)
37 (15)
76 (32)
106 (44)
269 (100)
136 (50)
2 (1-3)
107 (22)
134 (27)
134 (27)
117 (24)
308 (62)
356 (71)
8 (5-10)
Admission creatinine value
<92 mol/l
92-115 mol/l
116-149 mol/l
> 150 mol/l
Post CA shock, n(%)
Therapeutic hypothermia, n(%)
Delay between CA and ICU
death, days, median (IQR)
789 (68)
764 (66)
5 (2-9)
% are taking into account missing data
SD=Standard deviation
CPR= Cardiopulmonary Resuscitation
VF/VT=Ventricular Fibrillation/Ventricular Tachycardia
ROSC= Restoration of Spontaneous Circulation
OHCA=Out-of Hospital Cardiac Arrest
ICU=Intensive Care Unit
IQR= Interquartile (p25-p75)
p-value
0.001
0.169
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
Table 2 ESM Multivariate analysis according to mode of death (result from multiples imputations).
Imputated variables: location (n=3), bystander CPR (n=22), creatinine level (n=36), lactate level (n=185), time
to ROSC (n=146)
Deaths related to post
cardiac arrest shock
n=269
Deaths related to neurological
injury
n=499
OR Ratio (95% CI)
OR (95% CI)
p-value
Age, yrs
1.02 [1.01-1.04]
0.001
1.01 [1.0-1.02]
0.047
Male gender, n(%)
0.83 [0.51-1.34]
0.93
0.89[0.61-1.30]
0.55
CPR by bystander, n(%)
0.70 [0.45-1.09]
0.12
0.56 [0.41-0.78]
0.001
Cardiac arrest Location, n(%) (home vs
public area)
0.68 [0.44-1.06]
0.09
0.59 [0.42-0.83]
0.002
Shockable rhythm, n(%)
0.40 [0.25-0.61]
<0.001
0.32 [0.22-0.45]
<0.001
Time from Collapse to ROSC
1.88[1.47-2.40]
<0.001
1.76 [1.49-2.07]
<0.001
Admission lactate
2.58 [1.98-3.36]
<0.001
1.58[1.33-1.88]
<0.001
Admission creatinine
1.55[1.25-1.92]
<0.001
1.20[1.03-1.41]
0.02
Post-CA shock, n(%)
-
-
0.85 [0.61-1.19]
0.35
0.35 [0.23-0.54]
<0.001
1.04 [0.74-1.47]
0.82
Therapeutic hypothermia, n(%)
OR= Odds Ratio
* reference value is survivors (n=386)
CPR= Cardiopulmonary Resuscitation
VF/VT=Ventricular Fibrillation/Ventricular Tachycardia
ROSC= Restoration of Spontaneous Circulation
OHCA=Out-of Hospital Cardiac Arrest
p-value