Abstract
Early prediction of the mortality, neurological outcome is clinically essential after successful cardiopulmonary resuscitation. To find a prognostic marker among unselected cardiac arrest survivors, we aimed to evaluate the alterations of the l-arginine pathway molecules in the early post-resuscitation care. We prospectively enrolled adult patients after successfully resuscitated in- or out-of-hospital cardiac arrest. Blood samples were drawn within 6, 24, and 72 post-cardiac arrest hours to measure asymmetric and symmetric dimethylarginine (ADMA and SDMA) and l-arginine plasma concentrations. We recorded Sequential Organ Failure Assessment, Simplified Acute Physiology Score, and Cerebral Performance Category scores. Endpoints were 72 h, intensive care unit, and 30-day mortality. Among 54 enrolled patients [median age: 67 (61–78) years, 48% male], the initial ADMA levels were significantly elevated in those who died within 72 h [0.88 (0.64–0.97) µmol/L vs. 0.55 (0.45–0.69) µmol/L, p = 0.001]. Based on receiver operator characteristic analysis (AUC = 0.723; p = 0.005) of initial ADMA for poor neurological outcome, the best cutoff was determined as > 0.65 µmol/L (sensitivity = 66.7%; specificity = 81.5%), while for 72 h mortality (AUC = 0.789; p = 0.001) as > 0.81 µmol/L (sensitivity = 71.0%; specificity = 87.5%). Based on multivariate analysis, initial ADMA (OR = 1.8 per 0.1 µmol/L increment; p = 0.002) was an independent predictor for 72 h mortality. Increased initial ADMA predicts 72 h mortality and poor neurological outcome among unselected cardiac arrest victims.
Highlights
Management of post-resuscitation care, including postcardiac arrest syndrome, ischemic brain injury, myocardial dysfunction, and multiple organ failure (MOF) remains an unmet clinical challenge with high mortality
Successful resuscitation was defined as the return of spontaneous circulation (ROSC). 23 patients admitted to the intensive care unit (ICU) of the 1st Department of Medicine, 18 patients to the Department of Anaesthesiology and Intensive Care, and 13 patients from the Department of Emergency Medicine were enrolled in our cohort
The results showed that the Area Under the Curve (AUC) of SAPS II and initial ADMA were comparable reflecting similar sensitivity and specificity in prediction of 72 h mortality, in contrast Sequential Organ Failure Assessment (SOFA) provided poor prognostic information for mortality [SAPS II AUC: 0.817 (0.688–0.946), p < 0.001; ADMA AUC: 0.789 (0.628–0.950), p = 0.001; SOFA AUC: 0.608 (0.433–0.783), p = 0.232]
Summary
Management of post-resuscitation care, including postcardiac arrest syndrome, ischemic brain injury, myocardial dysfunction, and multiple organ failure (MOF) remains an unmet clinical challenge with high mortality. Internal and Emergency Medicine of neurological outcome after resuscitation from cardiac arrest [4]. To improve the quality of prognostication after cardiac arrest, addressing the role of extracerebral causes of death is warranted [5]. One-fourth of patients who suffered IHCA die due to neurological injury, while most of them may reach acceptable neurological function but suffer from MOF which may lead to death [6]. A reliable biomarker that can be used in unselected resuscitated patients would provide useful information about the general outcome and survival without focusing only on the neurological status
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