1. The association between global hemodynamics, cerebral oxygenation and survival in post-cardiac arrest patients K. Ameloot, I. Meex, C. Genbrugge, F. Jans, W. Mullens, M. Dupont, C. DeDeyne, J. Dens

2. The Clinical Problem, 42 yrs OOHCA 10’ bystander CPR VF, DC shock -> ROSC Inferior STEMI (R/PPCI) TH by Coolgard

3. The Clinical Problem - No vaso-active drugs - CO 2 41mmHg

5. The Clinical Problem

6. ‘PCAS is a sepsis-like syndrome’ At least 2 major differences with sepsis: 1.Rightward shift autoregulation 2.Cardiac patient = afterload dependent The optimal MAP should maintain cerebral perfusion without exposing the damaged myocardium to excessive afterload

8. Aims SctO 2 MAP SVO2 GuidelinesSctO 2 Mortality > 65 mmHg > 70 %

9. Prospective observational trial Study Patients 82 PCA survivors between 3/2011-2/2014 – NIRS (n=82) – Arterial line (n=82) – Swann-Ganz (n=63) Exclusion criteria: – Traumatic cause – Death < 24 hrs – Early withdrawal therapy Treatment Protocol General management – MAP 65mmHg – Saturation > 94% – Normocapnia Therapeutic hypothermia – Cooled IV NaCl 0.9 % – 24hrs 33°C – Rewarming 0.3°C / hour

11. n = 1 pair/2 sec x 24 hrs (=hypothermia) = 1 625 141

12. MAP dependent MAP independent y=0.99x+57.99 y=0.00x+67 87 mmHg 67%

13. Excessive afterload Maintain SctO2

14. n=1 625 141

15. SVO2 72% SctO2 67% MAP 87mmHg Ventriculo-arterial-cerebral coupling

16. SVO2 67-72% CPC1-3 180 days OR 8.24 95%CI [2.08; 32.68] P=0.001

17. OR95% CIp-value Bystander CPR<10minyes/no19.90[1.78;222.11]0.02 Initial rhythm shockableyes/no1.85[0.52;6.64]0.34 SVO2 [67,72] %yes/no8.79[1.69;18.36]0.01 Multivariate Model (SVO2)

18. MAP 76-86mmHg CPC1-3 180 days OR 2.64 95%CI [1.01;6.88] P=0.04

19. OR95% CIp-value Bystander CPR<10minyes/no13.41[2.35;76.48]0.003 Initial rhythm shockableyes/no3.26[1.11;9.52]0.03 MAP[76,86] mmHgyes/no3.88[1.22;12.33]0.02 Multivariate Model (MAP)

20. SVO2<67% MAP<76mmHg Poor Outcome Patient Characteristics Causality  Target for treatment? Association  Marker of prognosis?

21. All Per SVO2 LowTargetHigh p-value ≤ 66%[67,72]%≥ 73% Number patients8227/63 (43%)18/63 (29%) Demographics Age (years)63±1366±1460±1060±160.23 Male (%)70±4659±5083±3872±460.22 Resuscitation parameters Out of Hospital (%)85±3693±2789±3384±370.65 Bystander CPR<10 min (%)82±3980±4089±3262±500.14 Initial Rhythm Shockable (%)66±4850±5189±3266±490.02 Cardiac Cause90±3093±2794±2483±380.46 Surface Cooling (%)52±5059±5044±51 0.51 Hemodynamic parameters Heartrate (BPM)68±1671±1766±1375±130.20 Echocardiographic LVEF (%)42±1734±1845±1745±160.05 MAP (mmHg)76±874±875±679±90.11 CVP (mmHg)17±1316±718±1815±90.73 mPAP (mmHg)26±526±625±425±60.78 dPAP (mmHg)19±520±519±318±50.35 SVO2 (%)67±959±770±278±3<0.0001 TDCCO (l/min)3.88±1.263.24±1.233.97±0.754.79±1.19<0.0001 Cerebral Saturation (%)65±464±465±568±40.01

22. High SVO2  /  High Mortality 1. Causality Hypothesis Hyperdynamic circulation  cerebral hypersaturation Target for treatment? 2. Reduced oxygen consumption Functional brain death

23. All Per SVO2 LowTargetHigh p-value ≤ 66%[67,72]%≥ 73% Number patients8227/63 (43%)18/63 (29%) Demographics Age (years)63±1366±1460±1060±160.23 Male (%)70±4659±5083±3872±460.22 Resuscitation parameters Out of Hospital (%)85±3693±2789±3384±370.65 Bystander CPR<10 min (%)82±3980±4089±3262±500.14 Initial Rhythm Shockable (%)66±4850±5189±3266±490.02 Cardiac Cause90±3093±2794±2483±380.46 Surface Cooling (%)52±5059±5044±51 0.51 Hemodynamic parameters Heartrate (BPM)68±1671±1766±1375±130.20 Echocardiographic LVEF (%)42±1734±1845±1745±160.05 MAP (mmHg)76±874±875±679±90.11 CVP (mmHg)17±1316±718±1815±90.73 mPAP (mmHg)26±526±625±425±60.78 dPAP (mmHg)19±520±519±318±50.35 SVO2 (%)67±959±770±278±3<0.0001 TDCCO (l/min)3.88±1.263.24±1.233.97±0.754.79±1.19<0.0001 Cerebral Saturation (%)65±464±465±568±40.01

24. The Clinical Problem

25. Summary SctO 2 MAP SVO2 GuidelinesSctO 2 Mortality > 65 mmHg > 70 % 67 % 87 mmHg 72 % 76-86 mmHg 67-72%

26. Back-up slides

31. Hemoglobin and outcome Hb (g/dl) ORLLCULCP-value 160.700.172.810.61 151.890.625.720.26 141.550.604.030.36 131.780.744.290.20 122.881.028.160.04 111.520.327.280.60 101.110.158.270.92

32. Hemoglobin and Outcome The suggested optimal Hemoglobin seems to be 12 g/dl… … Odds ratio driven by patients below target SVO2 ORLLCULCP-value All2.881.028.160.04 SVO2 < 70%6.251.3229.430.01 SVO2 ≥ 70%1.000.0617.900.33

36. n = 1 pair/2 sec x 24 hrs (=hypothermia) = 1 625 141