Variation in Sedation and Neuromuscular Blockade Regimens on Outcome After Cardiac Arrest

Objectives: Sedation and neuromuscular blockade protocols in patients undergoing targeted temperature management after cardiac arrest address patient discomfort and manage shivering. These protocols vary widely between centers and may affect outcomes. Design: Consecutive patients admitted to 20 centers after resuscitation from cardiac arrest were prospectively entered into the International Cardiac Arrest Registry between 2006 and 2016. Additional data about each center’s sedation and shivering management practice were obtained via survey. Sedation and shivering practices were categorized as escalating doses of sedation and minimal or no neuromuscular blockade (sedation and shivering practice 1), sedation with continuous or scheduled neuromuscular blockade (sedation and shivering practice 2), or sedation with as-needed neuromuscular blockade (sedation and shivering practice 3). Good outcome was defined as Cerebral Performance Category score of 1 or 2. A logistic regression hierarchical model was created with two levels (patient-level data with standard confounders at level 1 and hospitals at level 2) and sedation and shivering practices as a fixed effect at the hospital level. The primary outcome was dichotomized Cerebral Performance Category at 6 months. Setting: Cardiac arrest receiving centers in Europe and the United states from 2006 to 2016 Patients: Four-thousand two-hundred sixty-seven cardiac arrest patients 18 years old or older enrolled in the International Cardiac Arrest Registry. Interventions: None. Measurements and Main Results: The mean age was 62 ± 15 years, 36% were female, 77% out-of-hospital arrests, and mean ischemic time was 24 (± 18) minutes. Adjusted odds ratio (for age, return of spontaneous circulation, location of arrest, witnessed, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation, medical history, country, 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 sedation and shivering practice 2 and sedation and shivering practice 3, respectively, referenced to sedation and shivering practice 1. Conclusion: Cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders. These findings should be further investigated in prospective studies. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by the National Center for Advancing Translational Sciences, National Institutes of Health, Grant Number KL2TR001063. Dr. May’s institution received funding from Tufts Clinical and Translational Science Institute Career development award (KL2) supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), Grant Number KL2TR0010063. Drs. May and Kent received support for article research from the NIH. Dr. Fraser disclosed off-label product use of all sedatives mentioned (with the exception of midazolam and dexmedetomidine). Dr. Nielsen received funding from Bard Medical (lecture fee) and BrainCool (advisory board). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: tmay@mmc.org Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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