Elsevier

Resuscitation

Volume 80, Issue 6, June 2009, Pages 624-630
Resuscitation

Clinical paper
Derangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: A report from the national registry of cardiopulmonary resuscitation

https://doi.org/10.1016/j.resuscitation.2009.02.011Get rights and content

Abstract

Study aims

Hyperglycemia is associated with poor outcomes in critically ill patients. We examined blood glucose values following in-hospital cardiac arrest (IHCA) to (1) characterize post-arrest glucose ranges, (2) develop outcomes-based thresholds of hyperglycemia and hypoglycemia, and (3) identify risk factors associated with post-arrest glucose derangements.

Methods

We retrospectively studied 17,800 adult IHCA events reported to the National Registry of Cardiopulmonary Resuscitation (NRCPR) from January 1, 2005 through February 1, 2007.

Results

Data were available from 3218 index events. Maximum blood glucose values were elevated in diabetics (median 226 mg/dL [IQR, 165–307 mg/dL], 12.5 mmol/L [IQR 9.2–17.0 mmol/L]) and non-diabetics (median 176 mg/dL [IQR, 135–239 mg/dL], 9.78 mmol/L [IQR 7.5–13.3 mmol/L]). Unadjusted survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3–47.6%] vs. 41.7% [95% CI, 38.9–44.5%], p = 0.037). Non-diabetics displayed decreased adjusted survival odds for minimum glucose values outside the range of 71–170 mg/dL (3.9–9.4 mmol/L) and maximum values outside the range of 111–240 mg/dL (6.2–13.3 mmol/L). Diabetic survival odds decreased for minimum glucose greater than 240 mg/dL (13.3 mmol/L). In non-diabetics, arrest duration was identified as a significant factor associated with the development of hypo- and hyperglycemia.

Conclusions

Hyperglycemia is common in diabetics and non-diabetics following IHCA. Survival odds in diabetics are relatively insensitive to blood glucose with decreased survival only associated with severe (>240 mg/dL, >13.3 mmol/dL) hyperglycemia. In non-diabetics, survival odds were sensitive to hypoglycemia (<70 mg/dL, <3.9 mmol/L).

Introduction

Despite initial resuscitation rates of 40–67%, in-hospital cardiac arrest (IHCA) outcomes remain poor with less than 20% of victims surviving to hospital discharge.1, 2, 3 Many cardiac arrest victims who achieve return of spontaneous circulation (ROSC) eventually succumb to a post-resuscitation syndrome characterized by hemodynamic instability, maladaptive inflammation, metabolic derangements, and impaired neurological recovery.4 Glucose homeostasis and insulin-mediated signaling are important in the pathophysiology of critical illness and may be useful as a determinant of outcomes following resuscitation from cardiac arrest. Retrospective studies of patients successfully resuscitated from out-of-hospital cardiac arrest (OOHCA) have suggested that hyperglycemia is common during the post-resuscitation period and may be associated with worse outcomes.5, 6, 7, 8, 9 A recent multi-center analysis of patients admitted to intensive care units after receiving cardiopulmonary resuscitation (CPR) for presumed IHCA or OOHCA demonstrated an association between hospital mortality and lowest blood glucose concentration measured during the first 24 h.10

Several clinical trials have suggested that aggressive treatment of hyperglycemia may improve morbidity and mortality in critically ill patients.11, 12, 13 However, a recent meta-analysis of 29 randomized control trials with a combined enrollment of 8432 adult ICU patients demonstrated that while tight glucose control was associated with a decreased rate of septicemia, this was balanced by an increased risk for severe hypoglycemia (glucose ≤40 mg/dL, ≤2.2 mmol/L) and no improvement in hospital mortality.14 Furthermore, recent studies have shown that tight glucose control through intensive insulin therapy may not necessarily improve outcomes in the critically ill subpopulation of cardiac arrest patients.15, 16 Recognizing the need for specific blood glucose control guidelines for post-cardiac arrest patients, the International Liaison Committee on Resuscitation (ILCOR) has recently recommended a more moderate target for blood glucose concentration of up to 144 mg/dL (8 mmol/L).17, 18 Development of a better understanding of blood glucose regulation following IHCA is an important step towards the creation of more specific glucose control guidelines to improve outcomes. Accordingly, our objective was to examine the association between post-arrest blood glucose concentrations and outcomes in patients with and without a history of preexisting diabetes.

Section snippets

Methods

Consecutive IHCA data from 311 participating hospitals during a 25-month period between January 1, 2005 and February 1, 2007 were analyzed from The National Registry of Cardiopulmonary Resuscitation (NRCPR). Sponsored by the American Heart Association (AHA), the NRCPR is a prospective, voluntary, multi-site registry which collects Utstein-style variables of in-hospital resuscitation events.19, 20, 21 IHCA data is abstracted from medical records by specially trained personnel at each

Results

Of the 17,800 consecutive IHCA events, 15,410 were index events with 8172 patients (53.0%) achieving initial return of spontaneous circulation (ROSC) (Fig. 1). Maximum and minimum glucose values were available for 3218 patients. Table 1 describes patient demographic and arrest event characteristics of the diabetic and non-diabetic patients with glucose values.

Post-ROSC maximum blood glucose values (Table 2) were elevated in diabetic (median 226 mg/dL [165–307 mg/dL], 12.6 mmol/L [9.2–17.1 mmol/L])

Discussion

In this study of IHCA, hyperglycemia was commonly exhibited by both diabetic and non-diabetic patients during the immediate post-ROSC period. In agreement with our results, several retrospective clinical studies have suggested that hyperglycemia is commonly exhibited by patients following OOHCA and IHCA.5, 6, 7, 8, 9, 10 Furthermore, other studies have suggested that hyperglycemia may worsen outcomes in a variety of critically ill patient populations including sepsis, trauma, acute coronary

Limitations

This study has several limitations. Given the retrospective design of this study, we were unable to establish a causal relationship between hyperglycemia, hypoglycemia, and survival outcomes. Also, since pre-arrest measurements were not available in this NRCPR database, it is possible that some of the observed derangements in glucose actually preceded their index arrest events. Our study was unable to account for the possible effects of post-resuscitation quality of care and other unmeasured

Conclusions

Our results suggest that hyperglycemia is common following IHCA in both diabetics and non-diabetics. Furthermore, survival odds in diabetics may be relatively insensitive to large variations in blood glucose with decreased survival only associated with extreme (>240 mg/dL, >13.3 mmol/L) hyperglycemia. By comparison, survival in non-diabetics appears more sensitive to derangements in blood glucose outside a range of minimum (71–170 mg/dL, 3.9–9.4 mmol/L) and maximum (111–240 mg/dL, 6.2–13.3 mmol/L)

Conflicts of interest statement

Dr. Peberdy is an unpaid member of the Scientific Advisory Board and co-chair of the Adult Research Task Force of the NRCPR. The authors have no financial conflicts of interest to report.

Acknowledgements

The authors would like to acknowledge Kimberly Wojcik and Michael Retzer for their editorial assistance. In addition, we would like to acknowledge Theodore Karrison, Ph.D. from the University of Chicago's Biostatistics Laboratory. Also, we would like to thank the Scientific Advisory Board and staff at the NRCPR and AHA including Scott Carey for his assistance with the database.

Dr. Beiser acknowledges the support of the K12 Scholars Program, Clinical and Translational Science Award (CTSA) from

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      Both multivariate regression analysis and propensity-matched analysis indicated that dextrose administration was inversely associated with favourable neurological and survival outcomes.6 Nevertheless, BG level was not accounted for in the study by Peng et al.6 Also analysing the data from GWTG-R, Beiser et al.9 indicated that non-DM patients were sensitive to hypoglycaemia (BG level < 70 mg/dl) during the early post-ROSC periods. For other critically ill patients, hypoglycaemia (BG level < 70 mg/dl) has also been associated with mortality in a dose-dependent manner, i.e. the lower the BG level, the higher the mortality was.7

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.02.011.

    d

    For the American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators.

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