Variation in Sedation and Neuromuscular Blockade Regimens on Outcome After Cardiac Arrest
Sedation and neuromuscular blockade (NMB) protocols in patients undergoing targeted
temperature management (TTM) after cardiac arrest address patient discomfort and manage
shivering. These protocols vary widely between centers and may affect outcomes. Methods:
Consecutive patients admitted to 20 centers after resuscitation from cardiac arrest were
prospectively entered ... read moreinto the International Cardiac Arrest Registry between 2004-2016.
Additional data about each center's sedation and shivering management practice was
obtained via survey. Sedation and shivering practices (SP) were categorized as deep
sedation and minimal or no NMB (SP1), moderate-deep sedation with continuous or
scheduled NMB (SP2), or moderate-deep sedation with as-needed NMB (SP3). Good outcome
was defined as cerebral performance category (CPC) score of 1 or 2. A logistic
regression hierarchical model was created with two levels (patient-level data with
standard confounders at level one and hospitals at level two) and sedation practice as a
random effect at the hospital level. The primary outcome was dichotomized CPC at 6
months and the secondary outcome was dichotomized CPC at ICU discharge. Results: A total
of 4,267 patients were included, with mean age 62±15 years, 36% female, 77%
out-of-hospital arrests, and mean ischemic time was 24(±18) minutes. The unadjusted
odds ratio (OR) for good outcome at 6 months was 1.19 (0.88-1.42, p=0.07) and 1.65
(1.40-1.97, p<0.001) for SP2 and SP3 respectively, referenced to SP1. Adjusted odds
ratio (for age, ischemic time, location of arrest, witnessed, initial rhythm, bystander
CPR, and defibrillation, medical history and size of hospital) was 1.13 (0.74-1.73,
p=0.56) and 1.45 (1.00-2.13, p=0.046) for SP2 and SP3 respectively, referenced to SP1.
For the secondary endpoint of good outcomes at discharge, the unadjusted odds ratio for
SP2 and SP3 was 1.10 (0.90-1.34, p=0.34) and 1.69 (1.41-2.01, p<0.001), with adjusted
odds ratios of 0.86 (0.55-1.35, p-0.52) and 1.46 (0.97-2.20, p=0.07), respectively.
Discussion: Cardiac arrest patients treated at centers using moderate-deep sedation and
as-needed NMB had increased odds of good outcomes compared to centers using deep
sedation and avoidance of NMB, even after adjusting for potential confounders. Using
sedation alone to treat shivering associated with TTM could be harmful. These findings
should be further investigated in prospective
Thesis (M.S.)--Tufts University, 2018.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: David Kent.
Committee: Farzad Noubary, Douglas Sawyer, and Gilles Fraser.
Keyword: Medicine.read less