Clinical paperHypoxic hepatitis after out-of-hospital cardiac arrest: Incidence, determinants and prognosis☆
Introduction
Despite significant advances in post-cardiac arrest (CA) care,1 hospital mortality remains high in out-of-hospital cardiac arrest (OHCA) patients in whom pre-hospital cardiopulmonary resuscitation (CPR) allowed return of spontaneous circulation (ROSC).2, 3 In these patients, mortality in the intensive care unit (ICU) is triggered by both post-CA shock (and associated organ damages) and brain injury.3
The post-ROSC period is characterized by the onset of the post-CA syndrome that encompasses all manifestations of the systemic ischemia/reperfusion (I/R) injury induced by CA and CPR.4 This systemic I/R injury mostly affects the brain and may worsen the neurological prognosis but may also trigger multiple organ damage, which may potentially be worsened by a post-CA shock occurring in nearly 70% of case.3
Few studies are applied to described the epidemiology and the prognostic impact of organ damage after CA.5, 6, 7, 8, 9 Particularly, liver damages occurring after CA are understudied.9 Primary experimental description of hepatic consequences of CA allowed to link the observed biological and histological hepatic abnormalities after CA to the hypoxic hepatitis (HH) entity,10 better known under the old appellation of “ischemic hepatitis” or “shock liver”.11 Recently, many observational studies have described the biological course and have assessed the outcome of HH, particularly in critically ill patients.12, 13, 14, 15, 16, 17 However, OHCA patients are underrepresented in these studies.
Aims of this study were to describe the prevalence and the development of HH in a cohort of OHCA patients admitted in ICU after ROSC. Secondary goals were to investigate the factors associated with the occurrence of HH and to evaluate the association of HH with the ICU mortality in this population.
Section snippets
Study design and population
All consecutive patients admitted in our tertiary medical ICU (Cochin University Hospital, Paris, France) between January 2009 and December 2014 after a non-traumatic OHCA followed by ROSC were included in the study. OHCA patients without liver function tests (LFT) performed during the first 72 h were excluded, as well as patients who died in the first 24 h after admission. Patients who presented an in-hospital cardiac arrest were not included in the present study. The ethic committee of the
Baseline characteristics
During the study period (2009–2014), 807 patients were admitted to our CA center after OHCA following ROSC. Among them, 174 patients died during the first 24 h following ICU admission and biological data (LFT) were not available for one patient. Thus, 632 patients were included in the present study (Fig. 1). Baseline characteristics are detailed in Table 1. Eighteen (2.8%) patients had a pre-existing hepatic illness. Most of these CA (88.3%) were witnessed and CPR was bystander-initiated in 59%
Discussion
In our study including 632 patients admitted in ICU after ROSC following OHCA over a 6-year period, we observed a prevalence of HH of 11.4% (95% CI: 9.0%, 14.1%) and we found that the occurrence of HH was associated with ICU mortality. Furthermore, delay from collapse to ROSC, gender and initial rhythm were factors associated with the development of HH.
A small number of studies had previously described the evolution and the prognosis of HH in various clinical settings but only one study was
Conclusions
Occurrence of HH is a common complication after OHCA that is mainly triggered by the duration of resuscitation and that is strongly associated with ICU mortality. Further studies are needed to evaluate liver functions in this setting and to evaluate the relationship between hepatic damage induced by CA and early mortality in ICU.
Conflict of interest statement
None of the authors has a financial relationship with a commercial entity that has an interest in the purpose of this manuscript.
Authors’ contribution
B.C., G.G., and A.C. designed the study, collected, analyzed, and interpreted the data, and wrote the manuscript. W.B., F.D., M.A., L.Z., F.P., J.C. and J.P.M. contributed to design the study and to review the manuscript. G.G. performed the statistical analysis. B.C. takes the full responsibility for the integrity of the work. All authors read and approved the final version of the manuscript.
Acknowledgment
We thank Nancy Kentish-Barnes for her help in preparing the manuscript.
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2019, ResuscitationCitation Excerpt :To date, only two studies evaluated the occurrence of HLI after CA in OHCA setting.9,10 HLI occurred with a prevalence of 11.4%9–13.5%10. In contrast, we found an almost doubled prevalence of 21% in patients with IHCA and OHCA.
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2018, ResuscitationCitation Excerpt :However that study had a very small size (n = 35) and excluded all patients with liver or renal failure. These conditions are frequently observed in post-cardiac arrest patients [14,30] and are associated with reduced clearance of sedative drugs [31]. An increased duration of mechanical ventilation may translate into a higher risk of nosocomial complications.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.03.021.