Postarrest Steroid Use May Improve Outcomes of Cardiac Arrest Survivors

Min-Shan Tsai, MD, PhD; Po-Ya Chuang, MHA; Chien-Hua Huang, MD, PhD; Chao-Hsiun Tang, PhD; Ping-Hsun Yu, MD; Wei-Tien Chang, MD, PhD; Wen-Jone Chen, MD, PhD

Disclosures

Crit Care Med. 2019;47(2):167-175. 

In This Article

Abstract and Introduction

Abstract

Objectives: To evaluate the ramifications of steroid use during postarrest care.

Design: Retrospective observational population-based study enrolled patients during years 2004–2011 with 1-year follow-up.

Setting: Taiwan National Health Insurance Research Database.

Patients: Adult nontraumatic cardiac arrest patients in the emergency department, who survived to admission.

Interventions: These patients were classified into the steroid and nonsteroid groups based on whether steroid was used or not during hospitalization. A propensity score was used to match patient underlying characteristics, steroid use prior to cardiac arrest, the vasopressors, and shockable rhythm during cardiopulmonary resuscitation, hospital level, and socioeconomic status.

Measurements and Main Results: There were 5,445 patients in each group after propensity score matching. A total of 4,119 patients (75.65%) in the steroid group died during hospitalization, as compared with 4,403 patients (80.86%) in the nonsteroid group (adjusted hazard ratio, 0.74; 95% CI, 0.70–0.77; p < 0.0001). The mortality rate at 1 year was significantly lower in the steroid group than in the nonsteroid group (83.54% vs 87.77%; adjusted hazard ratio, 0.73; 95% CI, 0.70–0.76; p < 0.0001). Steroid use during hospitalization was associated with survival to discharge, regardless of age, gender, underlying diseases (diabetes mellitus, chronic obstructive pulmonary disease, asthma), shockable rhythm, and steroid use prior to cardiac arrest.

Conclusions: In this retrospective observational study, postarrest steroid use was associated with better survival to hospital discharge and 1-year survival. (Crit Care Med 2019; 47:167–175)

Introduction

Cardiac arrest is a rapidly lethal condition and associated with a high mortality rate, even after successful resuscitation. Following the return of spontaneous circulation (ROSC), postcardiac arrest syndrome, a complex combination of pathophysiologic processes that involve cerebral injury, myocardial dysfunction, systemic ischemia-reperfusion injury, and inflammatory response accounts for most hemodynamic instability and mortality during the postcardiac arrest period. Postcardiac arrest syndrome shares many features with severe sepsis and multiple organ failures such as increased cytokine production and release, endotoxinemia,[1,2] coagulation abnormality,[3,4] and adrenal dysfunction.[5,6]

Several studies have shown that relative adrenal insufficiency is common during the postcardiac arrest period,[5–9] and may cause impaired vasoregulation and reduced effectiveness of vasopressors, and thus result in postresuscitation shock.[5,6] Schultz et al[5] reported that circulating cortisol levels in patients with out-of-hospital cardiac arrest (OHCA) were lower than those in patients with other stress conditions. Furthermore, a low serum cortisol level was associated with unstable hemodynamics after ROSC and short-term survival (24 hr). Hékimian et al[6] also reported that OHCA survivors with refractory shock and early mortality had lower cortisol levels than those who died later. Additionally, relative adrenal insufficiency has been reported to be a prognostic factor for early death (within 7 d after admission) and in-hospital mortality.[7–9] In two randomized controlled trials conducted by Mentzelopoulos et al,[10,11] patients who received vasopressin, epinephrine, and methylprednisolone during cardiopulmonary resuscitation (CPR) and stress-dose hydrocortisone during postcardiac arrest shock displayed a higher frequency of ROSC, better hemodynamic stability, less organ dysfunction, and a better rate of survival to hospital discharge with a favorable neurologic status when compared with patients who received epinephrine alone. However, because multiple interventions were used simultaneously, it was difficult to clarify which of the interventions were truly beneficial. Furthermore, it was difficult to discern the isolated effect of glucocorticoid use during postcardiac arrest care on the outcomes, because the ROSC rates in the study groups were significantly different. Conversely, several other studies do not support the use of glucocorticoids during the postcardiac arrest period, because those drugs did not significantly improve survival or neurologic outcomes.[12–14]

The benefit of steroid supplement during CPR has been documented in several animal and human studies.[15–17] In the current study, we hypothesized that steroid use during the postcardiac arrest period may be associated with improved patient outcomes. Therefore, we analyzed data from the Taiwan National Health Insurance Research Database (NHIRD) to determine potential associations between post-ROSC exposure to steroids and critical cardiac arrest outcomes.

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