Elsevier

Resuscitation

Volume 103, June 2016, Pages 60-65
Resuscitation

Clinical paper
Hypoxic hepatitis after out-of-hospital cardiac arrest: Incidence, determinants and prognosis

https://doi.org/10.1016/j.resuscitation.2016.03.021Get rights and content

Abstract

Aim

Hypoxic hepatitis (HH) may complicate the course of resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted in intensive care unit (ICU). Aims of this study were to assess the prevalence of HH, and to describe the factors associated with HH occurrence and outcome.

Methods

We conducted an observational study over a 6-year period (2009–2014) in a cardiac arrest center. All non-traumatic OHCA patients admitted in the ICU after return of spontaneous circulation (ROSC) and who survived more than 24 h were included. HH was defined as an elevation of alanine aminotransferase over 20 times the upper limit of normal during the first 72 h after OHCA. Factors associated with HH and ICU mortality were picked up by multivariate logistic regression.

Results

Among the 632 OHCA patients included in the study, HH was observed in 72 patients (11.4% (95% CI: 9.0%, 14.1%)). In multivariate analysis, time from collapse to ROSC [OR 1.02 per additional minute; 95% CI (1.00, 1.04); p = 0.01], male gender [OR 0.53; 95% CI (0.29, 0.95); p = 0.03] and initial shockable rhythm [OR 0.35; 95% CI (0.19, 0.65); p < 0.01] were associated with HH occurrence. After adjustment for confounding factors, HH was associated with ICU mortality [OR 4.39; 95% CI (1.71, 11.26); p < 0.01] and this association persisted even if occurrence of a post-CA shock was considered in the statistical model [OR 3.63; 95% CI (1.39, 9.48); p = 0.01].

Conclusions

HH is not a rare complication after OHCA. This complication is mainly triggered by the duration of resuscitation and is associated with increased ICU mortality.

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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    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.

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