Post-Arrest Care

When patients present following cardiac arrest, a continuing controversy has been the utility of emergency coronary angiography. In patients presenting with suspected ST-segment elevation myocardial infarction, the advantage seems clear. In those presenting with nondiagnostic electrocardiographic findings, the observational evidence likewise seems to support intervention. However, the first randomized trial evidence is trickling out now, and the Coronary Angiography after Cardiac Arrest (COACT) study found no clear benefit.⁸ This is the first of what are likely to be many forthcoming study reports, but it is the highest-quality evidence we have to date.

Another recent study reports on the expansion of therapeutic hypothermia to those presenting to the emergency department after cardiac arrest with a nonshockable rhythm.9 The overall survival of this population is dismal, comparatively, with 90-day mortality of greater than 80 percent. The use of targeted temperature management (TTM) in this population was observed to provide a small absolute advantage in neurologically intact survival, increasing the justification of using TTM in this population. However, deviations from TTM resulted in febrile episodes in the normothermia cohort only. Failure to prevent these episodes may have contributed to poorer outcomes and muddies the reliability of this trial’s observations. It may still be that the most critical thing we can do is to prevent fevers in these patients. 

Sepsis Steps Forward and Backward

Despite abundant face validity to the observation that all patients suffering overwhelming infection are not the same, our sepsis protocols offer little room for reasonable variation. Researchers at the University of Pittsburgh finally provided some hard data to back up better differentiation of those presenting with sepsis, performing a complex analysis of cytokine and gene expression in response to infection.¹⁰ Their data show clear differing phenotypes among what we currently just call “sepsis,” with a wide range of mortality for each phenotype, as well as variable enrichment of clinical trials with the differing phenotypes. While their analysis does not provide any specifically actionable utility, this demonstration should help future research better tailor interventions to specific subgroups of sepsis patients.

Meanwhile, the Early Goal Directed Therapy Using a Physiological Holistic View (ANDROMEDA-SHOCK) investigators put the classic lactic acid clearance target as a marker of sepsis treatment success to the test.¹¹ In one arm of this study, patients were resuscitated per protocol as guided by serial lactic acid measurements, or to clinical peripheral perfusion targets. In the other arm, investigators used glass slides and held manual pressure to the distal tips of patients’ fingers, then observed the length of time necessary for capillary perfusion to occur. At 28-day follow-up, all-cause mortality was 43.4 percent in the lactic acid clearance arm compared to 34.9 percent in those resuscitated to peripheral perfusion targets. The study was small enough that this difference in mortality could have occurred by chance alone, but it certainly provides a note of concern regarding even the most well-known practices underpinning our current approach to sepsis.

Lastly, we are beginning to receive the first trickle of results regarding the importance of high-dose vitamin repletion in sepsis. The Vitamin C Infusion for Treatment in Sepsis Induced Acute Lung Injury (CITRIS-ALI) trial started before much of the hullabaloo over combining steroids, thiamine, and vitamin C for patients with septic shock, and it looked solely at the use of vitamin C for reducing organ failure in a subgroup of patients with septic shock and acute respiratory distress syndrome.¹² In this small study, there were no differences in sequential organ failure scores within 96 hours, but 28-day mortality was 29.8 percent in the vitamin C arm compared to 46.3 percent with placebo. These data must be considered exploratory, however, owing to the structure of the trial, and we will need to await more robust results to have reliable information regarding the utility of vitamins in sepsis. (Turn to page 1 for more on recent research on vitamin C and sepsis.)

The opinions expressed herein are solely those of Dr. Radecki and do not necessarily reflect those of his employer or academic affiliates