Significance of arterial hypotension after resuscitation from cardiac arrest

Objective: Expert guidelines advocate hemodynamic optimization after return of spontaneous circulation (ROSC) from cardiac arrest despite a lack of empirical data on prevalence of post-ROSC hemodynamic abnormalities and their relationship with outcome. Our objective was to determine whether post-ROSC arterial hypotension predicts outcome among postcardiac arrest patients who survive to intensive care unit admission. Design: Cohort study utilizing the Project IMPACT database (intensive care unit admissions from 120 U.S. hospitals) from 2001-2005. Setting: One hundred twenty intensive care units. Patients: Inclusion criteria were: 1) age >= 18 yrs; 2) nontrauma; and 3) received cardiopulmonary resuscitation before intensive care unit arrival. Interventions: None. Measurements and Main Results: Subjects were divided into two groups: 1) Hypotension Present-one or more documented systolic blood pressure <90 mm Hg within 1 hr of intensive care unit arrival; or 2) Hypotension Absent-all systolic blood pressure >= 90 mm Hg. The primary outcome was in-hospital mortality. The secondary outcome was functional status at hospital discharge among survivors. A total of 8736 subjects met the inclusion criteria. Overall mortality was 50%. Post-ROSC hypotension was present in 47% and was associated with significantly higher rates of mortality (65% vs. 37%) and diminished discharge functional status among survivors (49% vs. 38%), p <.001 for both. On multivariable analysis, post-ROSC hypotension had an odds ratio for death of 2.7 (95% confidence interval, 2.5-3.0). Conclusions: Half of postcardiac arrest patients who survive to intensive care unit admission die in the hospital. Post-ROSC hypotension is common, is a predictor of in-hospital death, and is associated with diminished functional status among survivors. These associations indicate that arterial hypotension after ROSC may represent a potentially treatable target to improve outcomes from cardiac arrest. (Crit Care Med 2009; 37:2895-2903)