Analyse de l’influence des interventions thérapeutiques précoces au sein d’une cohorte de patients survivants d’arrêt cardio-respiratoire

Abstract : Background: Out-of-Hospital Cardiac Arrest (OHCA), usually clinically described as “sudden death”, is the leading worldwide cause of death. Despite recent improvements in management of OHCA, the prognosis of these patients remains very poor, even in those who benefitted from a successful initial resuscitation. During the period of ischemia following the Return of Spontaneous Circulation (ROSC), several pathophysiological phenomenons occur, characterizing the post cardiac arrest syndrome. Furthermore, different treatments, such as immediate coronary reperfusion or therapeutic hypothermia, are now implemented for the management of this syndrome in order to decrease the morbidities and the mortality involved during this period. However, the influence of these hospital interventions on prognosis is still debatable, since they have been assessed in very selected subgroups of patients.Objectives: The aim of our work was to assess the influence of these early interventions on the outcome of OHCA patients admitted alive in intensive care unit (ICU).Method: We set up an investigation cohort (starting in 2000) of OHCA patients, in whom a successful ROSC had been obtained and who were admitted alive in ICU. We gathered all demographic data, cardiac arrest circumstances, pre-hospital and hospital characteristics. We analyzed the different predictive factors of outcome using multivariate analysis, especially logistical regression.Results: Between 2003 and 2008, 435 patients without obvious extra-cardiac cause were included and benefited from an immediate and systematical coronary angiogram. We observed a recent lesion in nearly half of them. Detecting a cardiac etiology is very challenging even using simple predictive models including patient’s baseline characteristics and circumstances of the cardiac arrest. Moreover, other parameters, such as EKG patterns or cardiac biomarkers, did not seem helpful either. Indeed, these parameters had poor predictive values and consequently could not be considered as triage tools for these patients. Nevertheless, the immediate and systematical coronary angiogram, with percutaneous intervention if appropriate, was independently associated with an improvement of hospital survival (adjusted OR= 2.06 (1.16-3.66)), regardless of the EKG pattern.Between 2000 and 2009, 1145 patients were admitted and two third of them were treated with therapeutic hypothermia. Among them, 708/1145 (62%) had an initial shockable rhythm and 437/1145 (38%) presented a non shockable rhythm. On the one hand, after adjustment with other predictive factors, the therapeutic hypothermia significantly improved the good neurological outcome at ICU discharge (adjusted OR= 1.90 (1.18-3.06)). On the other hand, the influence of this intervention was not associated with prognosis on the “non-shockable” sub-group (adjusted OR=0.71 (0.37-1.36)). Among the undercurrent factors, which could minimize the benefit of this intervention, infectious complications in treated patients were common. The most frequent complication was early onset pneumonia, whose occurrence was significantly associated with hypothermia (adjusted OR= 1.90 (1.28-2.80)), even if its role on prognosis was not determined.Conclusions: Our findings support the international guidelines regarding the management of post-cardiac arrest, identifying the subgroups of patients who may benefit the most. These results encourage further prospective studies and randomized trials and bring helpful information in that way. Finally, ancillary analysis on an investigation cohort of hospital survivors suggests that protective
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Florence Dumas. Analyse de l’influence des interventions thérapeutiques précoces au sein d’une cohorte de patients survivants d’arrêt cardio-respiratoire. Médecine humaine et pathologie. Université René Descartes - Paris V, 2012. Français. ⟨NNT : 2012PA05S006⟩. ⟨tel-00711998⟩

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