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Predictors of Neurologic Outcome in Patients Resuscitated From Out-of-Hospital Cardiac Arrest Using Classi Fi Cation and Regression Tree Analysis
Predictors of Neurologic Outcome in Patients Resuscitated From Out-of-Hospital Cardiac Arrest Using Classi Fi Cation and Regression Tree Analysis
Predictors of Neurologic Outcome in Patients Resuscitated From Out-of-Hospital Cardiac Arrest Using Classi Fi Cation and Regression Tree Analysis
1025
Table 1
Characteristics of the study population (n 184)
Characteristics
Age (years)
Men
Women
Ventricular brillation or ventricular
tachycardia
Pulseless electrical activity
Asystole
Citizen witnessed
Paramedic witnessed
Unwitnessed
Bystander cardio-pulmonary resuscitation
Field return of spontaneous circulation
Emergency department return of
spontaneous circulation
Time to resuscitation (minutes)
Lactate (mmol/L)
Survival to hospital discharge
Survival with GCS of 14 or 15
(36%)
(28%)
(63%)
(14%)
(24%)
(32%)
(79%)
(21%)
1026
Table 2
Characteristics by outcome (n 184)
Characteristic
Age (years)
Men
Shockable rhythm
Witnessed arrest
Bystander cardiopulmonary resuscitation
Field return of spontaneous circulation
Time to resuscitation (minutes)
Epinephrine administered (mg)
Lactate (mmol/L)
Survival to hospital discharge
GCS 14 or 15 (n 43)
p-Value
0.03
0.5
<0.0001
0.04
0.03
<0.01
<0.0001
<0.0001
<0.01
<0.0001
Table 3
Adjusted odds ratios for baseline predictors of favorable neurologic
outcome
Variable
Age
Witnessed arrest
Shockable rhythm
Bystander cardiopulmonary
resuscitation
Time to return of spontaneous
circulation
Emergency department as site of
resuscitation
Lactate
Epinephrine
(0.94e1.01), p 0.2
(0.3e4.1), p 0.9
(1.4e10.0), p 0.01
(0.5e4.6), p 0.4
such care is costly and resource intensive. Our study demonstrates that receiving as little as1.5 mg of epinephrine
during resuscitation efforts and an admission lactate level
>5 mmol/L, which is about twice the upper limit of normal
in our institutions laboratory, are associated with poor
neurologic outcome at hospital discharge. Such data are
likely to be available within an hour of admission to the ED.
Early identication of predictors of neurologic outcome is
important to help identify which patients should be
considered for aggressive postresuscitation care. Dened
and generally accepted predictors of outcome after resuscitation from OHCA have focused on survival to hospital
discharge, whereas few studies have addressed postresuscitation neurologic outcome.
Our study support observations that epinephrine administration during advanced cardiac life support may improve
the rate of return of spontaneous circulation but not the rate
of survival to hospital discharge.4e6 However, there are
important differences between our report and previously
published data. Two previous studies were observational,
retrospective, cohort studies similar to ours but differed in
that the analysis of epinephrine use was dichotomized,
rather than leaving epinephrine as a continuous variable.6,7
Additionally, one study did not include modern postresuscitation care, namely therapeutic hypothermia and
coronary intervention, in the analysis of outcome. Three
other studies evaluated cumulative epinephrine dose and
long-term outcome,8e10 but none of these studies included
postresuscitation interventions in the analysis. Finally, we
used CART analysis, which has a number of advantages
over other analytic methods including multivariate logistic
regression. CART is inherently nonparametric, and no assumptions are made regarding the underlying distribution of
values of the predictor variables. Additionally, CART can
handle missing data by repeated sampling techniques, as
well as data that are highly skewed or multimodal and
categorical predictors with either ordinal or nonordinal
structure.
It is generally believed that blood lactate concentration
after resuscitation from cardiac arrest is predictive of
outcome. However, published studies yield conicting results, most likely due to methodological study differences.
Muller et al11 demonstrated a weak correlation between
admission lactate levels and cardiac arrest duration and that
the initial lactate level was poorly predictive of neurologic
outcome. Donnino et al12 and Starodub et al13 demonstrated
1027
Table 4
Association of patient characteristics of epinephrine administration in the eld (n 184)
Variable
Age (years)
Male gender
Shockable arrest rhythm
Witnessed arrest
Bystander CPR
Field ROSC
Time to resuscitation (minutes)
Lactate (mmol/L)
Survival to hospital discharge
Survival with GCS of 14 or 15
Epinephrine (n 160)
No Epinephrine (n 24)
N (median)
% IQR
N (median)
% (IQR)
65
79
48
117
67
121
22
5.8
56
27
55e77
50
30
74
42
76
18e32
3.0e9.9
35
17
60.5
18
18
23
17
24
13.5
2.9
19
16
52e68
75
75
96
71
100
9e18
1.8e4
79
67
that lactate clearance rather than the initial lactate level was
a better predictor of survival to hospital discharge. Two
studies have demonstrated that median initial lactate levels
are lower in patients with a good neurologic outcome14 or
who survive15 and that outcome is related to estimated arrest
duration but variably related to arrest rhythm. Adrie et al14
included epinephrine dose as a study variable and found it
to be insignicant when included in the multivariate analysis, whereas Oddo et al15 did not include epinephrine. It is
not surprising that we and others identied the admission
lactate level as a potential predictor of eventual outcome
because restoration of cerebral function depends on alleviating global ischemia, and lactate levels reect the degree of
ischemia during arrest and resuscitation. Thus, a lower
lactate level may indicate that cerebral perfusion was relatively well maintained. In our study, we demonstrated a
lactate cut point value of 5 mmol/L, which approximates the
median value of 3.1 mmol/L in patients with a good
neurologic outcome reported by Adrie et al, but is much
lower than the median of 8 mmol/L reported in survivors by
Oddo et al. After adjusting for epinephrine administration,
the initial lactate level was no longer predictive in our nal
multivariate logistic regression analysis and CART.
Oddo et al did not show that initial rhythm, witness
status, and bystander CPR were important variables when
therapeutic hypothermia was included in the analysis.15
Our study also failed to demonstrate that arrest-related
variables that constitute the chain of survival for OHCA
were important predictors of good neurologic outcome at
discharge.
Our study has a number of limitations: the study population is from a single center, limiting the generalizability. The
study design is a retrospective cohort review and is subject to
the biases that are inherent in a retrospective analysis. Our
study sample is of modest size for this kind of epidemiologic
study, with 184 patients and 43 subjects achieving the desired
outcome. However, our sample size is greater than that of
Oddo et al15 (n 77) and approximates the derivation (n
130) and validation (n 210) sets of Adrie et al.14 Although
we used a partitioning approach to our modeling, our results
should be viewed as exploratory and warrant validation in
larger populations. Our institution is a teaching hospital with
percutaneous coronary intervention capability and a large ED
volume. Specically, in this study population, 115 patients
OR (95% CI)
p-Value
(0.1e0.9)
(0.1e0.4)
(0.1e0.9)
(0.1e0.8)
0.1 (0.1e0.4)
0.1 (0.1e0.4)
0.3
0.03
<0.0001
0.02
<0.01
<0.01
<0.0001
<0.001
<0.0001
<0.0001
0.3
0.1
0.1
0.3
1028
9.
10.
11.
12.
13.
administered during human CPR on hemodynamic, oxygen transport, and utilization variables in the postresuscitation period. Chest
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Behringer W, Kittler H, Sterz F, Domanovits H, Shoerkhuber W,
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2014 Elsevier