Clinical paperDerangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: A report from the national registry of cardiopulmonary resuscitation☆
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
References (32)
- et al.
A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation
Resuscitation
(2003) Effect of an intensive glucose management protocol on the mortality of critically ill adult patients
Mayo Clin Proc
(2004)- et al.
Strict normoglycaemic blood glucose levels in the therapeutic management of patients within 12h after cardiac arrest might not be necessary
Resuscitation
(2008) - et al.
Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke
Resuscitation
(2008) - et al.
Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation
Resuscitation
(2003) - et al.
Tight blood glucose control with insulin in the ICU: facts and controversies
Chest
(2007) - et al.
In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway
Resuscitation
(2003) - et al.
Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest
JAMA
(2005) - et al.
First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults
JAMA
(2006) - et al.
In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival
Intens Care Med
(2007)
Postresuscitation disease after cardiac arrest: a sepsis-like syndrome?
Curr Opin Crit Care
Neurologic outcome and blood glucose levels during out-of-hospital cardiopulmonary resuscitation
Neurology
Glycemia in the post-resuscitation period. The Cerebral Resuscitation Study Group
Resuscitation
Blood glucose and neurologic outcome with global brain ischemia
Crit Care Med
Blood glucose concentration after cardiopulmonary resuscitation influences functional neurological recovery in human cardiac arrest survivors
J Cereb Blood Flow Metab
Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database
Anaesthesia
Cited by (75)
Treatment of hyperglycaemia during hospitalization and its association with inpatient mortality
2021, Endocrinologia, Diabetes y NutricionNeurologic complications of cardiac arrest
2021, Handbook of Clinical NeurologyPediatric Cardiac Arrest Resuscitation
2020, Emergency Medicine Clinics of North AmericaAssociations between intra-arrest blood glucose level and outcomes of adult in-hospital cardiac arrest: A 10-year retrospective cohort study
2020, ResuscitationCitation Excerpt :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
- ☆
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.